Basic Information
| Provider Information | |||||||||
| NPI: | 1598714420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHEATON FRANCISCAN HEALTHCARE - ELMBROOK MEMORIAL, INC. | ||||||||
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| OtherOrganizationName: | ELMBROOK MEMORIAL HOSPITAL, INC/ | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19333 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530454132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627852000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19333 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530454132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627852000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | STANDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2627852000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 183 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5000019 | 01 | WI | UNITED HEALTHCARE PROVIDE | OTHER | 11019400 | 05 | WI | MEDICAID |