Basic Information
| Provider Information | |||||||||
| NPI: | 1184673352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOWARD YOUNG MEDICAL CENTER INC OF WOODRUFF WISCONSIN | ||||||||
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| OtherOrganizationName: | EMERGENCY DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29980 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545689190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
| FaxNumber: | 7153568286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP - REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOWARD YOUNG MEDICAL CENTER, INC | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 282N00000X | 201 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 32886500 | 05 | WI | MEDICAID |