Provider Demographics
NPI:1104426477
Name:ST GIANNA MOLLA CLINIC, INC
Entity type:Organization
Organization Name:ST GIANNA MOLLA CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-716-1451
Mailing Address - Street 1:1716 LAWRENCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9108
Mailing Address - Country:US
Mailing Address - Phone:920-605-3115
Mailing Address - Fax:920-486-6826
Practice Address - Street 1:1716 LAWRENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9108
Practice Address - Country:US
Practice Address - Phone:920-605-3115
Practice Address - Fax:920-486-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100163645Medicaid