NPIMap

Organization Active NPI

Agnesian Healthcare Inc

Doing business as SSM Health Fond Du Lac Regional Clinic

  • Family Medicine Physician
  • Fond Du Lac, WI
National Provider Identifier
1730162991
Registry record updated Jun 5, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
AGNESIAN HEALTHCARE INC
Doing business as
SSM Health Fond Du Lac Regional Clinic
Practice address
420 E Division St
Fond Du Lac, WI 54935-4560
Phone
(920) 923-7400
NPI assigned
Nov 22, 2005
Last updated
Jun 5, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 2024

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

Authorized official

Name
Amy J Grinnell
Title
VP-Finance, Cfo
Phone
(608) 260-3586

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X NU
Anesthesiology Physician 207L00000X NU
Dermatology Physician 207N00000X NU
Family Medicine Physician 207Q00000X NU Primary
Internal Medicine Physician 207R00000X NU
Obstetrics & Gynecology Physician 207V00000X NU
Ophthalmology Physician 207W00000X NU
Orthopaedic Surgery Physician 207X00000X NU
Otolaryngology Physician 207Y00000X NU
Pediatrics Physician 208000000X NU
Physical Medicine & Rehabilitation Physician 208100000X NU
Surgery Physician 208600000X NU
Urology Physician 208800000X NU
Podiatrist 213E00000X NU
Durable Medical Equipment & Medical Supplies 332B00000X NU

Addresses

Primary practice location

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

Mailing address

1808 W Beltline Hwy
Madison, WI 53713-2334
Phone (608) 250-1593

Other identifiers 3

IdentifierTypeStateIssuer
38437100MedicaidWI
32841900MedicaidWI
CY0124OtherWIRAILROAD MEDICARE GRP #

Other names 1

  • SSM HEALTH FOND DU LAC REGIONAL CLINIC Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031104000263 WI Part B Supplier - Clinic/Group Practice 1658289624 Receives reassigned benefits from 630 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory

Member organizations 14

Organizations listed as members of this organization in the National Provider Directory.

View all 14

Locations

305 Camelot Dr
Fond du Lac, WI 54935
Phone (920) 923-2333

Practitioners & affiliated clinicians

Practitioners 384

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.

View all 384

NPI Registry JSON

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

{
    "created_epoch": "1132617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717545600000",
    "number": "1730162991",
    "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",
            "telephone_number": "608-250-1593"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-923-7400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGNESIAN HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-22",
        "last_updated": "2024-06-05",
        "certification_date": "2024-06-05",
        "status": "A",
        "authorized_official_last_name": "GRINNELL",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "VP-FINANCE, CFO",
        "authorized_official_telephone_number": "608-260-3586"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207L00000X",
            "taxonomy_group": "",
            "desc": "Anesthesiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38437100",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32841900",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE GRP #",
            "identifier": "CY0124",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "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 Jun 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.