=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497878854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOX VALLEY HEMATOLOGY & ONCOLOGY, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 01/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 614 MEMORIAL DR CALUMET MEDICAL CENTER
-----------------------------------------------------
City | CHILTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53014-1568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-849-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3232 N BALLARD RD SUITE 200
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-8804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-749-9668
-----------------------------------------------------
Fax | 920-734-5307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER/PHYSICIAN
-----------------------------------------------------
Name | TIMOTHY F GOGGINS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 920-749-1171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------