NPIMap

Organization Active NPI

Agnesian Healthcare Inc

Doing business as SSM Health Fond Du Lac Regional Clinic

  • Occupational Medicine Physician
  • Fond Du Lac, WI
National Provider Identifier
1508579202
Registry record updated Dec 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Occupational Medicine PhysicianTaxonomy code 2083X0100X
Legal business name
AGNESIAN HEALTHCARE INC
Doing business as
SSM Health Fond Du Lac Regional Clinic
Practice address
430 E Division St
Fond Du Lac, WI 54935-4560
Phone
(920) 926-5676
Fax
(920) 926-8930
NPI assigned
Dec 28, 2022
Last updated
Dec 28, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 28, 2022

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

Authorized official

Name
Amy Jo Grinnell
Title
VP-Finance
Phone
(608) 229-7885

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational Medicine Physician 2083X0100X NU Primary

Addresses

Primary practice location

430 E Division St
Fond Du Lac, WI 54935-4560

Mailing address

1808 W Beltline Hwy
Madison, WI 53713-2334

Other names 1

  • SSM HEALTH FOND DU LAC REGIONAL CLINIC Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Agnesian Healthcare27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1672185600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1672185600000",
    "number": "1508579202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1808 W BELTLINE HWY",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537132334"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "430 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-5676",
            "fax_number": "920-926-8930"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGNESIAN HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-12-28",
        "last_updated": "2022-12-28",
        "certification_date": "2022-12-27",
        "status": "A",
        "authorized_official_last_name": "GRINNELL",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "JO",
        "authorized_official_title_or_position": "VP-FINANCE",
        "authorized_official_telephone_number": "608-229-7885"
    },
    "taxonomies": [
        {
            "code": "2083X0100X",
            "taxonomy_group": "",
            "desc": "Preventive Medicine, Occupational Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM HEALTH FOND DU LAC REGIONAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fond Du Lac, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.