1023310034 NPI number — BEAVER DAM COMMUNITY HOSPITALS, INC

Table of content: (NPI 1023310034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023310034 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:
1023310034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2022
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:
705 S UNIVERSITY AVE STE 150
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-219-4009
Provider Business Practice Location Address Fax Number:
920-219-9709
Provider Enumeration Date:
11/23/2010

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: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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