Basic Information
Provider Information | |||||||||
NPI: | 1447759428 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BALDWIN AREA MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTERN WISCONSIN HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 BERGSLIEN ST | ||||||||
Address2: |   | ||||||||
City: | BALDWIN | ||||||||
State: | WI | ||||||||
PostalCode: | 540022600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156841111 | ||||||||
FaxNumber: | 7156841119 | ||||||||
Practice Location | |||||||||
Address1: | 503 CHERRY LN | ||||||||
Address2: |   | ||||||||
City: | ROBERTS | ||||||||
State: | WI | ||||||||
PostalCode: | 540239731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7157603311 | ||||||||
FaxNumber: | 7157603036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2018 | ||||||||
LastUpdateDate: | 02/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEDERSON | ||||||||
AuthorizedOfficialFirstName: | EILIDH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7156841100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.