1841376183 NPI number — PRAIRIE RIDGE HEALTH, INC.

Table of content: (NPI 1841376183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841376183 NPI number — PRAIRIE RIDGE HEALTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE RIDGE HEALTH, 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:
COLUMBUS COMMUNITY HEALTH, INC.
Provider Other Organization Name Type Code:
4
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:
1841376183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53925-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-623-2200
Provider Business Mailing Address Fax Number:
920-623-1441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53925-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-623-2200
Provider Business Practice Location Address Fax Number:
920-623-1441
Provider Enumeration Date:
10/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
920-623-1368

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  278-800 , 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: 1009297 . This is a "PHYSICIANS PLUS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11012810 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000093 . This is a "DEAN CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11012800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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