Basic Information
| Provider Information | |||||||||
| NPI: | 1730160011 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTHCARE OF WISCONSIN INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MEDICAL PROVIDERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6083561423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH ST CLARE HOSPITAL-BARABOO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 227900000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LA2100X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32880600 | 05 | WI | MEDICAID | 391023846028 | 01 | WI | BLUE CROSS PROV # | OTHER | 1009390 | 01 | WI | PHYS PLUS PROV # | OTHER | 391023846 | 01 | WI | COMMERCIAL INS PROV # | OTHER |