Basic Information
| Provider Information | |||||||||
| NPI: | 1386688240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM HEALTH CARE OF WISCONSIN, INC | ||||||||
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| OtherOrganizationName: | SSM HEALTH ST MARY'S HOSPITAL - MADISON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082586891 | ||||||||
| FaxNumber: | 6082270112 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
| FaxNumber: | 6082585221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | MINERATH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYSTEM DIR OF GOV REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6082586891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 71 | WI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 39080639301 | 01 | WV | UNITY PROVIDER NUMBER | OTHER | 390806393026 | 01 | WI | BLUE CROSS PROVIDER NUMBE | OTHER | 5283846 | 01 | WI | MEDICA PROVIDER NUMBER | OTHER | 390806393 | 01 | WI | OTHER INSURANCE PROVIDER | OTHER | 5389107 | 01 | WI | PHYSICIANS PLUS PROVIDER | OTHER | 67 | 01 | WI | DEANCARE PROVIDER NUMBER | OTHER | A5371501 | 01 | WI | JOHN DEERE PROVIDER NUMBE | OTHER | 11022900 | 01 | WI | WI MEDICAID PROVIDER NUMB | OTHER |