Basic Information
| Provider Information | |||||||||
| NPI: | 1508920356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRED HEART REHABILITATION INSTITUTE, INC. | ||||||||
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| OtherOrganizationName: | ASCENSION SACRED HEART REHABILITATION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 773446 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145856884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13111 N PORT WASHINGTON RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530972416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145856884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | HANSELMAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 165 | WI | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 11020000 | 05 | WI | MEDICAID |