1386641207 NPI number — SSM HEALTH CARE OF WISCONSIN INC

Table of content: (NPI 1386641207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386641207 NPI number — SSM HEALTH CARE OF WISCONSIN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSM HEALTH CARE OF WISCONSIN 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:
SSM HEALTH ST CLARE HOSPITAL-BARABOO
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:
1386641207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARABOO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53913-1539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-356-1400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARABOO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53913-1539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-356-1400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
608-356-1400

Provider Taxonomy Codes

  • Taxonomy code: 275N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 65 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1309280001 . This is a "DMERC PROV #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 70 . This is a "DEANCARE HMO VENDOR #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391023846028 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391023846 . This is a "FTN-COMMERCIAL PAYERS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11022800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391023846001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1009390 . This is a "PHYSICIANS PLUS PROV #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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