Basic Information
| Provider Information | |||||||||
| NPI: | 1780612317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOWARD YOUNG MEDICAL CENTER INC OF WOODRUFF WISCONSIN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMBULANCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 MAPLE ST | ||||||||
| Address2: | PO BOX 470 | ||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOWARD YOUNG MEDICAL CENTER INC | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 41346800 | 05 | WI | MEDICAID |