=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013995521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THEDACARE MEDICAL CENTER - WAUPACA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 RIVERSIDE DR
-----------------------------------------------------
City | WAUPACA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54981-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-258-1000
-----------------------------------------------------
Fax | 715-258-1626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 NEENAH CTR
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-830-5900
-----------------------------------------------------
Fax | 920-830-5910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. WILLIAM FLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-454-4013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 1038
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------