Basic Information
Provider Information | |||||||||
NPI: | 1790718542 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASPIRUS EAGLE RIVER HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASPIRUS EAGLE RIVER HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 11/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PECK | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7158472988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ASPIRUS EAGLE RIVER HOSPITAL, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1000 | WI | N |   | Hospitals | General Acute Care Hospital | Critical Access | 3416L0300X |   | WI | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 41341400 | 05 | WI |   | MEDICAID |