Basic Information
| Provider Information | |||||||||
| NPI: | 1710928221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION COLUMBIA ST MARY'S HOSPITAL MILWAUKEE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143262100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13111 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530972416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142704932 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | HANSELMAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 21280300 | 05 | WI | MEDICAID |