NPIMap

Organization Active NPI

St Gianna Molla Clinic, Inc

  • Multi-Specialty Clinic/Center
  • De Pere, WI
National Provider Identifier
1104426477
Registry record updated Apr 5, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
ST GIANNA MOLLA CLINIC, INC
Practice address
1716 Lawrence Dr Ste 100
De Pere, WI 54115-9108
Phone
(920) 605-3115
Fax
(920) 486-6826
NPI assigned
Oct 27, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robin Goldsmith
Title
President/Chief Medical Officer
Phone
(920) 716-1451

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X
Multi-Specialty Clinic/Center 261QM1300X Primary

Addresses

Primary practice location

1716 Lawrence Dr Ste 100
De Pere, WI 54115-9108

Mailing address

1716 Lawrence Dr Ste 100
De Pere, WI 54115-9108
Phone (920) 605-3115

Other identifiers 1

IdentifierTypeStateIssuer
100163645MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210129000133 WI Part B Supplier - Clinic/Group Practice 2163836339 Receives reassigned benefits from 11 practitioners
Practice locations: De Pere, WI

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D2213189St Gianna Clinics1716 Lawrence Drive, De Pere, WI 54115Certificate of waiverFeb 9, 2027

National Provider Directory

National Provider Directory

Locations

1716 Lawrence Dr
#100
De Pere, WI 54115
Phone (920) 605-3115

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1603756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1680652800000",
    "number": "1104426477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1716 LAWRENCE DR STE 100",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541159108",
            "telephone_number": "920-605-3115",
            "fax_number": "920-486-6826"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1716 LAWRENCE DR STE 100",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541159108",
            "telephone_number": "920-605-3115",
            "fax_number": "920-486-6826"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST GIANNA MOLLA CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-27",
        "last_updated": "2023-04-05",
        "certification_date": "2023-04-05",
        "status": "A",
        "authorized_official_last_name": "GOLDSMITH",
        "authorized_official_first_name": "ROBIN",
        "authorized_official_title_or_position": "PRESIDENT/CHIEF MEDICAL OFFICER",
        "authorized_official_telephone_number": "920-716-1451"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100163645",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in De Pere, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.