Basic Information
| Provider Information | |||||||||
| NPI: | 1346229697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTHCARE OF WI INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2006 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6083561400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH ST CLARE HOSPITAL-BARABOO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 52D0939990 | WI | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 391023846028 | 01 | WI | BLUE CROSS PROV # | OTHER | 32943300 | 05 | WI | MEDICAID | 391023846 | 01 | WI | COMMERCIAL INS PROV # | OTHER | 70 | 01 | WI | DEANCARE PROV # | OTHER | 1009390 | 01 | WI | PHYS PLUS PROV # | OTHER |