Basic Information
Provider Information | |||||||||
NPI: | 1396806659 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDGERTON HOSPITAL AND HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11101 N SHERMAN RD | ||||||||
Address2: |   | ||||||||
City: | EDGERTON | ||||||||
State: | WI | ||||||||
PostalCode: | 535349002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088843441 | ||||||||
FaxNumber: | 6088841669 | ||||||||
Practice Location | |||||||||
Address1: | 11101 N SHERMAN RD | ||||||||
Address2: |   | ||||||||
City: | EDGERTON | ||||||||
State: | WI | ||||||||
PostalCode: | 535349002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088843441 | ||||||||
FaxNumber: | 6088841669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 09/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROEDER | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6088841656 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EDGERTON HOSPITAL AND HEALTH SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 1022 | WI | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.