Basic Information
| Provider Information | |||||||||
| NPI: | 1053329581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROGERS MEMORIAL HOSPITAL INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROGERS BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34700 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626464411 | ||||||||
| FaxNumber: | 2626463158 | ||||||||
| Practice Location | |||||||||
| Address1: | 34700 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626464411 | ||||||||
| FaxNumber: | 2626463158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | HORVATH | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2626466318 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 283Q00000X | 190 | WI | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 10066300 | 05 | WI | MEDICAID | 43007500 | 05 | WI | MEDICAID | 43005800 | 05 | WI | MEDICAID | 10063800 | 05 | WI | MEDICAID | 43008100 | 05 | WI | MEDICAID |