Basic Information
| Provider Information | |||||||||
| NPI: | 1386641207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTH CARE OF WISCONSIN INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH ST CLARE HOSPITAL-BARABOO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6083561400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 65 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1309280001 | 01 | WI | DMERC PROV # | OTHER | 70 | 01 | WI | DEANCARE HMO VENDOR # | OTHER | 391023846028 | 01 | WI | BLUE CROSS/BLUE SHIELD | OTHER | 391023846 | 01 | WI | FTN-COMMERCIAL PAYERS | OTHER | 11022800 | 05 | WI | MEDICAID | 391023846001 | 05 | IL | MEDICAID | 1009390 | 01 | WI | PHYSICIANS PLUS PROV # | OTHER |