Provider Demographics
NPI:1699719310
Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Entity type:Organization
Organization Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-776-5500
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT SERVICES - SHP FL 2
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-0660
Mailing Address - Fax:
Practice Address - Street 1:536 KENNY DR
Practice Address - Street 2:
Practice Address - City:WAUSAUKEE
Practice Address - State:WI
Practice Address - Zip Code:54177-9627
Practice Address - Country:US
Practice Address - Phone:877-770-6983
Practice Address - Fax:715-856-6985
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHFIELD CLINIC HEALTH SYSTEM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21257100Medicaid
WI523989Medicare Oscar/Certification
21010Medicare PIN