1720202864 NPI number — BEAVER DAM COMMUNITY HOSPITALS INC

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 1720202864 NPI number — BEAVER DAM COMMUNITY HOSPITALS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAVER DAM COMMUNITY HOSPITALS 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:
Provider Other Organization Name Type Code:
6
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:
1720202864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 N OAK AVE
Provider Second Line Business Mailing Address:
ATTN: PROVIDER ENROLLMENT SERVICES/WWP
Provider Business Mailing Address City Name:
MARSHFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54449-5703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-389-0660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 S UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER DAM
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53916-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-887-4146
Provider Business Practice Location Address Fax Number:
920-887-6613
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CFO/COO/AO
Authorized Official Telephone Number:
715-387-5823

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  5344-042 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5344-042 . This is a "STATE LICENSE #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5111923 . This is a "NABP NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5111923 . This is a "WI MEDICAID NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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