Active NPI
Teresa J Wiersma, NP
- Family Nurse Practitioner
- Randolph, WI
National Provider Identifier
1417931833
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Nurse Practitioner
- License
- 125502
- Practice address
- 504 S High St
Randolph, WI 53956-1499 - Phone
- (920) 326-5060
- NPI assigned
- Nov 30, 2005
- Last updated
- Sep 15, 2016
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 125502 | WI | Primary |
Addresses
Primary practice location
504 S High St
Randolph, WI 53956-1499
Mailing address
504 S High St
PO Box 101
Randolph, WI 53956-1499
Phone (920) 326-5060
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 41253300 | Medicaid | WI | |
| 390807236CW | Other | WI | UNITY |
| P00206887 | Other | WI | RAILROAD MEDICARE |
| 13789 | Other | WI | DEAN |
| WI01S5 | Other | WI | JOHN DEERE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Nurse Practitioner
- Education
- Other, 2004
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
Practice addresses (Care Compare)
504 S High St
Randolph, WI 53956-1499
Phone (920) 326-5060
Hospital & facility affiliations
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 125502 | WI | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Divine Savior Healthcare, Inc. | Current | Accepting new patients | |
| Divine Savior Healthcare, Inc. | Current | Accepting new patients | |
| Randolph Community Clinic SC | Current | Accepting new patients |
Locations
29980 Network Pl
Chicago, IL 60673
2817 New Pinery Rd
Portage, WI 53901
Phone (608) 745-4598
504 S High St
Randolph, WI 53956
Phone (920) 326-5060
Interoperability endpoints
- teresa.wiersma.1@11574.direct.athenahealth.com
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Family Medicine Physician
- Randolph, WI
- NPI 1497832257
-
dba Aspirus Divine Savior Hospital
- General Acute Care Hospital
- Portage, WI
- NPI 1124083894
-
dba Aspirus Portage Clinic
- Rural Health Clinic/Center
- Portage, WI
- NPI 1386154417
Hospital & facility affiliations 7
Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.
-
dba Marshfield Medical Center - Beaver Dam
- General Acute Care Hospital
- Beaver Dam, WI
- NPI 1023187416
-
dba (Inactive) Marshfield Medical Center - Beaver Dam Specialty Clinic
- Clinic/Center
- Beaver Dam, WI
- NPI 1508184896
Hospital
-
- Critical Access Hospital
- Columbus, WI
- NPI 1154403657
-
- Critical Access Hospital
- Columbus, WI
- NPI 1841376183
-
dba SSM Health Waupun Memorial Hospital
- Medicare Defined Swing Bed Hospital Unit
- Waupun, WI
- NPI 1528046737
-
dba SSM Health Waupun Memorial Hospital
- Critical Access Hospital
- Waupun, WI
- NPI 1548248644
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1133308800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1473897600000",
"number": "1417931833",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "504 S HIGH ST",
"address_2": "PO BOX 101",
"city": "RANDOLPH",
"state": "WI",
"postal_code": "539561499",
"telephone_number": "920-326-5060"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "504 S HIGH ST",
"city": "RANDOLPH",
"state": "WI",
"postal_code": "539561499",
"telephone_number": "920-326-5060"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIERSMA",
"first_name": "TERESA",
"middle_name": "J",
"credential": "NP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-11-30",
"last_updated": "2016-09-15",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "WI",
"license": "125502",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "41253300",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITY",
"identifier": "390807236CW",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "P00206887",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DEAN",
"identifier": "13789",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "JOHN DEERE",
"identifier": "WI01S5",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Randolph, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- 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.