1770914384 NPI number — WATERTOWN REGIONAL MEDICAL CENTER, INC

Table of content: (NPI 1770914384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770914384 NPI number — WATERTOWN REGIONAL MEDICAL CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERTOWN REGIONAL MEDICAL CENTER, 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:
1770914384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 684088
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60695-4088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-262-4784
Provider Business Mailing Address Fax Number:
920-262-4640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W359N5002 BROWN ST
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-262-4371
Provider Business Practice Location Address Fax Number:
920-262-4441
Provider Enumeration Date:
12/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KLUGE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
DIRECTOR PATIENT ACCOUNTING
Authorized Official Telephone Number:
920-262-4784

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100035686 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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