Basic Information
| Provider Information | |||||||||
| NPI: | 1225075203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART REHABILITATION INSTITUTE, INC | ||||||||
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| OtherOrganizationName: | ASCENSION SACRED HEART REHABILITATION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860496 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860496 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2323 N LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145856884 | ||||||||
| FaxNumber: | 4142986737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | HANSELMAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 11020000 | 05 | WI | MEDICAID |