Basic Information
Provider Information | |||||||||
NPI: | 1053346825 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT ELIZABETHS HOSPITAL OF WABASHA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 GRANT BLVD W | ||||||||
Address2: |   | ||||||||
City: | WABASHA | ||||||||
State: | MN | ||||||||
PostalCode: | 559811042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6515654531 | ||||||||
FaxNumber: | 6515652482 | ||||||||
Practice Location | |||||||||
Address1: | 1200 GRANT BLVD W | ||||||||
Address2: |   | ||||||||
City: | WABASHA | ||||||||
State: | MN | ||||||||
PostalCode: | 559811042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6515654531 | ||||||||
FaxNumber: | 6515652482 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOLFE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6515655553 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SAINT ELIZABETHS HOSPITAL OF WABASHA INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 330554 | MN | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 125054 | 01 | MN | UCARE FOR HOME HEALTH | OTHER | 01015459 | 01 |   | PREFERRED ONE HOME HEALTH | OTHER | 1895AEL | 01 | MN | BCBS HOME HEALTH | OTHER | 41535100 | 05 | WI |   | MEDICAID |