Basic Information
Provider Information | |||||||||
NPI: | 1629056890 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROHEALTH WAUKESHA MEMORIAL HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 725 AMERICAN AVE | ||||||||
Address2: |   | ||||||||
City: | WAUKESHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531885031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2629282510 | ||||||||
FaxNumber: | 2629284032 | ||||||||
Practice Location | |||||||||
Address1: | 725 AMERICAN AVE | ||||||||
Address2: |   | ||||||||
City: | WAUKESHA | ||||||||
State: | WI | ||||||||
PostalCode: | 53188 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2629281000 | ||||||||
FaxNumber: | 2629287810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2006 | ||||||||
LastUpdateDate: | 12/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDWARDS | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2629282263 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 41 | WI | N |   | Hospital Units | Rehabilitation Unit |   | 273R00000X | 41 | WI | N |   | Hospital Units | Psychiatric Unit |   | 282N00000X | 41 | WI | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 11006600 | 05 | WI |   | MEDICAID |