NPIMap

Organization Active NPI

Thedacare Medical Center - Shawano, Inc.

  • Rural Health Clinic/Center
  • Clintonville, WI
National Provider Identifier
1801447925
Registry record updated May 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
THEDACARE MEDICAL CENTER - SHAWANO, INC.
Practice address
370 S Main St
Clintonville, WI 54929-1632
Phone
(715) 823-5161
Fax
(715) 823-1386
NPI assigned
Sep 20, 2019
Last updated
May 8, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 8, 2024

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

Authorized official

Name
William Flett
Title
Cfo
Phone
(920) 454-4013

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

370 S Main St
Clintonville, WI 54929-1632

Mailing address

3 Neenah Ctr
Neenah, WI 54956-3070
Phone (920) 454-4229

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191009003249 WI Part A Provider - Rural Health Clinic 5890605836 Practice locations: Clintonville, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801447925. Details of each certification follow.

Rural health clinic certification: CCN 528608

Legal name
THEDACARE MEDICAL CENTER - SHAWANO, INC.
Doing business as
SHAWANO MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 3, 2020
Last certification
Apr 3, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Oct 17, 1991 in WI
Enrollment address
370 S Main St
Clintonville, WI 54929-1632
Related CCNs
521346

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

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Shawano Community Hosp6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the 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
Froedtert Thedacare Health, Inc. Organization, Milwaukee, WI Corporation, Non-profit Operational/Managerial Control Jan 1, 2024
Jennifer R Glasheen Individual W-2 Managing EmployeePayer Contracting Jan 1, 2023
Laurie a Carter Individual Corporate DirectorBoard Member Feb 1, 2022
Thedacare, Incorporated Organization, Neenah, WI Corporation, Non-profit Operational/Managerial Control Jan 19, 2011
Mary W Goggans Individual Corporate DirectorBoard Member Feb 1, 2022
Alan Loux Individual Corporate DirectorBoard Member Jan 1, 2023
William Flett Individual Corporate OfficerCfo Jan 1, 2024
W-2 Managing EmployeeCfo Jan 1, 2024
Imran a Andrabi Individual Corporate DirectorCeo-President Jun 28, 2017
W-2 Managing EmployeeCeo-President Jun 28, 2017
Chuck Dallas Individual Corporate DirectorBoard Member Jan 1, 2021
David W Koeper Individual Corporate DirectorBoard Member Feb 11, 2021
Susan M Pahl Individual W-2 Managing EmployeeProvider Enrollment Jun 15, 2015
Steven J Price Individual Corporate DirectorBoard Member Jan 1, 2023
Kathleen Pigeon Individual W-2 Managing EmployeeProvider Enrollment Jun 11, 2020
Michael Morse Individual Corporate DirectorBoard Member Jan 1, 2024

Owners & managing parties with NPI records 14

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

View all 14

Facilities with the same owner 26

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1568937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715126400000",
    "number": "1801447925",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3 NEENAH CTR",
            "city": "NEENAH",
            "state": "WI",
            "postal_code": "549563070",
            "telephone_number": "920-454-4229",
            "fax_number": "920-993-5001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "370 S MAIN ST",
            "city": "CLINTONVILLE",
            "state": "WI",
            "postal_code": "549291632",
            "telephone_number": "715-823-5161",
            "fax_number": "715-823-1386"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THEDACARE MEDICAL CENTER - SHAWANO, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-20",
        "last_updated": "2024-05-08",
        "certification_date": "2024-05-08",
        "status": "A",
        "authorized_official_last_name": "FLETT",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "920-454-4013"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Clintonville, WI

Sources for this page

Verify at the official NPI Registry.