Provider Demographics
| NPI: | 1417993361 |
|---|---|
| Name: | FORT HEALTHCARE INC |
| Entity type: | Organization |
| Organization Name: | FORT HEALTHCARE INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | SHELBY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | WALLING |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 920-563-4466 |
| Mailing Address - Street 1: | PO BOX 249 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FORT ATKINSON |
| Mailing Address - State: | WI |
| Mailing Address - Zip Code: | 53538-0249 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 920-563-4402 |
| Mailing Address - Fax: | 920-568-4004 |
| Practice Address - Street 1: | 611 SHERMAN AVE E |
| Practice Address - Street 2: | |
| Practice Address - City: | FORT ATKINSON |
| Practice Address - State: | WI |
| Practice Address - Zip Code: | 53538-1960 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 920-568-6580 |
| Practice Address - Fax: | 920-568-4004 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-21 |
| Last Update Date: | 2022-10-07 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WI | 21273900 | Medicaid | |
| WI | 21274000 | Medicaid | |
| 000000491 | Other | MEDICARE PTAN | |
| WI | 21273800 | Medicaid | |
| WI | 21274200 | Medicaid | |
| WI | 21274600 | Medicaid | |
| WI | 21274500 | Medicaid | |
| WI | 21279400 | Medicaid | |
| WI | 11011900 | Medicaid | |
| WI | 21274300 | Medicaid | |
| WI | 21274900 | Medicaid | |
| WI | 21275700 | Medicaid | |
| WI | 21274100 | Medicaid | |
| WI | 21274800 | Medicaid | |
| WI | 52D0392916 | Other | CLIA |
| WI | 42237700 | Medicaid | |
| WI | 21274700 | Medicaid | |
| WI | 11011900 | Medicaid | |
| WI | 21274500 | Medicaid | |
| WI | 21273800 | Medicaid | |
| WI | 525620 | Medicare Oscar/Certification |
