Basic Information
| Provider Information | |||||||||
| NPI: | 1659355600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT ELIZABETHS HOSPITAL OF WABASHA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515654531 | ||||||||
| FaxNumber: | 6515652482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515654531 | ||||||||
| FaxNumber: | 6515652482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOLFE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6515655553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | 2005427 | MN | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 32949000 | 05 | WI | MEDICAID | 33160300 | 05 | WI | MEDICAID | 11004000 | 05 | WI | MEDICAID | 1895HEL | 01 | MN | BCBS FACILITY CHARGES | OTHER | 3990 | 01 | MN | HEALTH PARTNERS | OTHER | 01007855 | 01 | PREFERRED ONE HOSPITAL | OTHER | 2408931 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 300302 | 01 | MN | UCARE FOR HOSPITAL | OTHER | 32781400 | 05 | WI | MEDICAID | 36181TE | 01 | MN | BCBS PROFESSIONAL FEES | OTHER | 5000168 | 01 | MEDICA | OTHER | 394347000 | 05 | MN | MEDICAID | 60212EL | 01 | MN | BCBS CRNA CHARGES | OTHER |