1790796290 NPI number — GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN

Table of content: (NPI 1790796290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790796290 NPI number — GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN
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:
1790796290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44971
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53744-4971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-828-4811
Provider Business Mailing Address Fax Number:
608-828-4810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3051 CAHILL MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FITCHBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53711-7109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-661-7220
Provider Business Practice Location Address Fax Number:
608-661-7216
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLAGEL DEAN
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY OPERATIONS
Authorized Official Telephone Number:
608-828-4811

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0003X , with the licence number: 8468-42 , 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: 2110283 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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