Basic Information
| Provider Information | |||||||||
| NPI: | 1154350049 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGERTON HOSPITAL AND HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11101 N SHERMAN RD | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535349002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088843441 | ||||||||
| FaxNumber: | 6088841669 | ||||||||
| Practice Location | |||||||||
| Address1: | 11101 N SHERMAN RD | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535349002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088843441 | ||||||||
| FaxNumber: | 6088841669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROEDER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6088843441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1022 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 32831000 | 05 | WI | MEDICAID | 11008610 | 05 | WI | MEDICAID | 11008600 | 05 | WI | MEDICAID |