1619069630 NPI number — ST. CROIX VALLEY SURGICAL ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619069630 NPI number — ST. CROIX VALLEY SURGICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CROIX VALLEY SURGICAL ASSOCIATES
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:
1619069630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 3RD AVENUE
Provider Second Line Business Mailing Address:
PO BOX 597
Provider Business Mailing Address City Name:
OSCEOLA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54020-0597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-294-4898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 3RD AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSCEOLA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54020-0597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-294-4898
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
715-294-4898

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  38459 , 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: 32892400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38459 . This is a "WISCONSIN LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 36163 . This is a "MINNESOTA LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".