Basic Information
| Provider Information | |||||||||
| NPI: | 1124094263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM HEALTH TREATMENT AND RECOVERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1510 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561533 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 05/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6083561400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF WI INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 70 | 01 | WI | DEANCARE PROV # | OTHER | 391023846 | 01 | WI | COMMERCIAL PROV # | OTHER | 549696 | 01 | WI | DC OUTPATIENT PROV # | OTHER | 391023846028 | 01 | WI | BLUE CROSS PROV # | OTHER | 1009390 | 01 | WI | PHYS PLUS PROV # | OTHER |