Provider Demographics
NPI:1548248313
Name:THEDACARE MEDICAL CENTER - SHAWANO, INC.
Entity type:Organization
Organization Name:THEDACARE MEDICAL CENTER - SHAWANO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-454-4013
Mailing Address - Street 1:100 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-524-2169
Mailing Address - Fax:715-526-7140
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-524-2169
Practice Address - Fax:715-526-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI510315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43184400Medicaid
WI43184400Medicaid
521546Medicare ID - Type Unspecified