Basic Information
| Provider Information | |||||||||
| NPI: | 1558531251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF WISCONSIN SYSTEM NON PAYROLL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 1ST AVE W | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547511876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152321314 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 1ST AVE W | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547511876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152321314 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | RAMAEKER | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7152322114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | 34254-020 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 32118900 | 05 | WI | MEDICAID |