Basic Information
| Provider Information | |||||||||
| NPI: | 1720202864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAVER DAM COMMUNITY HOSPITALS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | (INACTIVE) HILLSIDE UNIT PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 707 S UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208874146 | ||||||||
| FaxNumber: | 9208876613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/COO/AO | ||||||||
| AuthorizedOfficialTelephone: | 7153875823 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHFIELD CLINIC HEALTH SYSTEM INC | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 5344-042 | WV | N | Hospitals | General Acute Care Hospital | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5344-042 | 01 | WI | STATE LICENSE # | OTHER | 5111923 | 01 | WI | NABP NUMBER | OTHER | 5111923 | 01 | WI | WI MEDICAID NUMBER | OTHER | AB5024322 | 01 | WI | DEA # | OTHER |