NPIMap

Organization Active NPI

Thedacare Medical Center - Wild Rose, Inc

Doing business as Waushara Family Physicians

  • Non-Pharmacy Dispensing Site
  • Wild Rose, WI
National Provider Identifier
1710018817
Registry record updated Jul 31, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Non-Pharmacy Dispensing SiteTaxonomy code 332900000X
License
47322-20 Issued in WI
Legal business name
THEDACARE MEDICAL CENTER - WILD ROSE, INC
Doing business as
Waushara Family Physicians
Practice address
701 Grove Ave
Wild Rose, WI 54984-6901
Phone
(920) 622-6013
Fax
(920) 774-1026
NPI assigned
Mar 8, 2007
Last updated
Jul 31, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 31, 2015

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

Authorized official

Name
Jenifer Danzeisen, RN
Title
Clinic Manager/ Director of Nu
Phone
(920) 622-5564

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Pharmacy Dispensing Site 332900000X 47322-20 WI Primary

Addresses

Primary practice location

701 Grove Ave
Wild Rose, WI 54984-6901

Mailing address

PO Box 314
Wild Rose, WI 54984-0314

Other identifiers 1

IdentifierTypeStateIssuer
2115407OtherPK

Other names 1

  • WAUSHARA FAMILY PHYSICIANS Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Wild Rose Community Mem3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

701 Grove Ave
Wild Rose, WI 54984
Phone (920) 361-5340

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1173312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1438300800000",
    "number": "1710018817",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 314",
            "city": "WILD ROSE",
            "state": "WI",
            "postal_code": "549840314"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 GROVE AVE",
            "city": "WILD ROSE",
            "state": "WI",
            "postal_code": "549846901",
            "telephone_number": "920-622-6013",
            "fax_number": "920-774-1026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THEDACARE MEDICAL CENTER - WILD ROSE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-08",
        "last_updated": "2015-07-31",
        "status": "A",
        "authorized_official_last_name": "DANZEISEN",
        "authorized_official_first_name": "JENIFER",
        "authorized_official_title_or_position": "CLINIC MANAGER/ DIRECTOR OF NU",
        "authorized_official_telephone_number": "920-622-5564",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "WI",
            "license": "47322-20",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2115407",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WAUSHARA FAMILY PHYSICIANS",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wild Rose, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 31, 2015; 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.