Basic Information
| Provider Information | |||||||||
| NPI: | 1770597445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSM HEALTH CARE OF WISCONSIN, INC | ||||||||
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| OtherOrganizationName: | SSM HEALTH ST. MARY'S HOSPITAL - MADISON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S. PARK ST. | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
| FaxNumber: | 6082585221 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S. PARK ST. | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
| FaxNumber: | 6082585221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | MINERATH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYSTEM DIR OF GOV REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6082586891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 71 | WI | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 32945300 | 05 | WI | MEDICAID |