1679558647 NPI number — STOUGHTON HOSPITAL ASSOCIATION

Table of content: (NPI 1679558647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679558647 NPI number — STOUGHTON HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOUGHTON HOSPITAL ASSOCIATION
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:
1679558647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/06/2015
NPI Reactivation Date:
11/19/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 RIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53589-1864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-873-6611
Provider Business Mailing Address Fax Number:
608-873-2255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 RIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53589-1864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-873-6611
Provider Business Practice Location Address Fax Number:
608-873-2255
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DEGROOT
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
608-873-2250

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  3804800 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 283Q00000X , with the licence number: 3804800 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 11007210 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78 . This is a "DEAN HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1009393 . This is a "PHYSICIANS PLUS HEALTH IN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11007200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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