Basic Information
| Provider Information | |||||||||
| NPI: | 1306864939 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT ELIZABETHS HOSPITAL OF WABASHA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515654531 | ||||||||
| FaxNumber: | 6515652482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515654531 | ||||||||
| FaxNumber: | 6515652482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLFE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6515655553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST ELIZABETH'S HOSPITAL OF WABASHA INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 330781 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 82693400 | 05 | WI | MEDICAID | 1895NEL | 01 | MN | BCBS NURSING HOME | OTHER | NH0451 | 01 | MN | UCARE FOR NURSING HOME | OTHER |