Basic Information
| Provider Information | |||||||||
| NPI: | 1780648659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS EAGLE RIVER HOSPITAL & CLINICS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPIRUS EAGLE RIVER HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29980 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472304 | ||||||||
| FaxNumber: | 7158431188 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545218835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154797411 | ||||||||
| FaxNumber: | 7154790395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASPIRUS EAGLE RIVER HOSPITAL & CLINICS, INC | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 1000 | WI | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 11018900 | 05 | WI | MEDICAID |