Basic Information
| Provider Information | |||||||||
| NPI: | 1184800468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPHS COMMUNITY HOSPITAL OF WEST BEND INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SYNERGY HEALTH - ST. JOSEPHS HOSPITAL (BHU) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 551 S SILVERBROOK DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530953868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623345533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3200 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623345533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | WESSING | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. FINANCIAL ANALYST - BUSINESS OF | ||||||||
| AuthorizedOfficialTelephone: | 2623345533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 44 | WI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 11011200 | 05 | WI | MEDICAID |