NPIMap

Organization Active NPI

Wild Rose Community Memorial Hospital Inc Dba Waushara Family Physicia

  • Family Medicine Physician
  • Wild Rose, WI
National Provider Identifier
1720029804
Registry record updated Mar 18, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC DBA WAUSHARA FAMILY PHYSICIA
Practice address
601 Grove Avenue
Wild Rose, WI 54984-0243
Phone
(920) 622-5560
NPI assigned
Jun 9, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2013

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

Authorized official

Name
Mr. Donald Caves
Title
President
Phone
(920) 622-5576

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

601 Grove Avenue
Wild Rose, WI 54984-0243

Mailing address

701 Grove Ave
Wild Rose, WI 54984-0243
Phone (920) 622-5560

Other identifiers 1

IdentifierTypeStateIssuer
32829100MedicaidWI

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070305000287 WI Part A Provider - Critical Access Hospital 6507840923 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wild Rose, WI

Hospital certification: CCN 52Z303

Legal name
THEDACARE MEDICAL CENTER - WILD ROSE, INC.
Organization structure
CorporationNon-profit
Incorporated
Oct 5, 1956 in WI
Enrollment address
601 Grove Ave
Wild Rose, WI 54984-6903
Other Hospital Practice Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Karen West Individual Corporate Director Jan 1, 2018
James Erdman Individual Corporate DirectorBoard Member May 22, 2007
Jennifer R Glasheen Individual W-2 Managing EmployeeDirector, Payer Contracting Jan 1, 2023
Thedacare, Incorporated Organization, Neenah, WI Corporation, Non-profit Operational/Managerial Control Jul 1, 2014
Carol R Williams Individual Corporate OfficerBoard Secretary/ Treasurer May 9, 2013
Tammy a Bending Individual Corporate DirectorBoard Member Jan 1, 2024
Sherry Brownlow Individual Corporate Director Jan 1, 2024
William Flett Individual Corporate Officer Oct 31, 2023
W-2 Managing Employee Oct 31, 2023
Chandler Donald Caves Individual Corporate Director Mar 31, 2018
Imran a Andrabi Individual Corporate OfficerCeo-President Jun 28, 2017
W-2 Managing Employee Jun 28, 2017
Paul Smith Individual Corporate DirectorBoard Member Jan 1, 2024
Buffy Lynn Detterman Individual Corporate Director Jan 1, 2024
Mark R Kjentvet Individual Corporate OfficerBoard Member May 22, 2007
Susan M Pahl Individual W-2 Managing EmployeeDelegated Official Jan 1, 2023

Owners & managing parties with NPI records 13

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 13

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1149811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1363564800000",
    "number": "1720029804",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "701 GROVE AVE",
            "city": "WILD ROSE",
            "state": "WI",
            "postal_code": "549840243",
            "telephone_number": "920-622-5560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "601 GROVE AVENUE",
            "city": "WILD ROSE",
            "state": "WI",
            "postal_code": "549840243",
            "telephone_number": "920-622-5560"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC DBA WAUSHARA FAMILY PHYSICIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-09",
        "last_updated": "2013-03-18",
        "status": "A",
        "authorized_official_last_name": "CAVES",
        "authorized_official_first_name": "DONALD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-622-5576",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32829100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wild Rose, WI

Sources for this page

Verify at the official NPI Registry.