Basic Information
| Provider Information | |||||||||
| NPI: | 1376062802 | ||||||||
| 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 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515654531 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 204 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546107722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515655599 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLFE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6515655553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT ELIZABETHS HOSPITAL OF WABASHA INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.