1154403657 NPI number — PRAIRIE RIDGE HEALTH, INC.

Table of content: (NPI 1154403657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154403657 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:
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:
1154403657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2020
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:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANGAN
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT/CFO
Authorized Official Telephone Number:
920-623-8453

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: 11012810 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36200200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: WI0105 . This is a "JOHN DEERE CRNA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 43414600 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32763600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: WI0100 . This is a "JOHN DEERE EKG, RT" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 41172200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: WI0104 . This is a "JOHN DEERE ER/UC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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