Basic Information
Provider Information | |||||||||
NPI: | 1689915209 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAVER DAM COMMUNITY HOSPITALS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | (INACTIVE) MARSHFIELD MEDICAL CENTER - BEAVER DAM HORICON CENTER (HOPD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 N OAK AVE | ||||||||
Address2: | ATTN: PROVIDER ENROLLMENT SERVICES/WWP | ||||||||
City: | MARSHFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 544495703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153890660 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 610 WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | HORICON | ||||||||
State: | WI | ||||||||
PostalCode: | 53032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206437170 | ||||||||
FaxNumber: | 9206437165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2013 | ||||||||
LastUpdateDate: | 03/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDWARDS | ||||||||
AuthorizedOfficialFirstName: | GORDON | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CFO/COO/AO | ||||||||
AuthorizedOfficialTelephone: | 7153875823 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 851-800 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.