Provider Demographics
| NPI: | 1114579836 |
|---|---|
| Name: | OCONTO HOSPITAL & MEDICAL CENTER INC |
| Entity type: | Organization |
| Organization Name: | OCONTO HOSPITAL & MEDICAL CENTER INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DENISE |
| Authorized Official - Middle Name: | K |
| Authorized Official - Last Name: | STROOBANTS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 920-433-7864 |
| Mailing Address - Street 1: | PO BOX 1866 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | GREEN BAY |
| Mailing Address - State: | WI |
| Mailing Address - Zip Code: | 54305-1866 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 920-445-7222 |
| Mailing Address - Fax: | 920-445-7289 |
| Practice Address - Street 1: | 820 ARBUTUS AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | OCONTO |
| Practice Address - State: | WI |
| Practice Address - Zip Code: | 54153-2004 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 920-835-1100 |
| Practice Address - Fax: | 920-835-1099 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | OCONTO HOSPITAL & MEDICAL CENTER, INC. |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2019-07-12 |
| Last Update Date: | 2022-05-20 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WI | 100092267 | Medicaid |
