1528491479 NPI number — GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WI - SAUK TRAILS CLINIC

Table of content: ERIC LEE WISE M.D. (NPI 1912224841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528491479 NPI number — GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WI - SAUK TRAILS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WI - SAUK TRAILS CLINIC
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:
Provider Other Organization Name Type Code:
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:
1528491479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1265 JOHN Q HAMMONS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53717-4971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-251-4156
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8202 EXCELSIOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-251-4156
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
QUADE
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
608-251-4156

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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