1124083894 NPI number — DIVINE SAVIOR HEALTHCARE, INC.

Table of content: (NPI 1124083894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124083894 NPI number — DIVINE SAVIOR HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE SAVIOR HEALTHCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASPIRUS DIVINE SAVIOR HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124083894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29980 NETWORK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-1299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-742-4131
Provider Business Mailing Address Fax Number:
608-742-6098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 NEW PINERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53901-9240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-742-4131
Provider Business Practice Location Address Fax Number:
608-742-6098
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PECK
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
VP REVENUE CYCLE
Authorized Official Telephone Number:
715-847-2988

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 3729800 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11009500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023054137 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1073596235 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1619966058 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1457334468 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1174508261 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1437132669 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1699959593 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1336122506 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1376527002 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1659589653 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1871576017 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1144203381 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1497738637 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1537142765 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1689657827 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1881677011 . This is a "INDIVIDUAL PHYSICIAN NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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