Basic Information
| Provider Information | |||||||||
| NPI: | 1811944093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARYS DEAN VENTURES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1305 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHITEWATER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531901503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624727686 | ||||||||
| FaxNumber: | 2624727691 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 TUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539133319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889684681 | ||||||||
| FaxNumber: | 6083557001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRINNELL | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6082603586 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARYS DEAN VENTURES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0200X | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 291U00000X | WI | N | Laboratories | Clinical Medical Laboratory | 261Q00000X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 32829800 | 05 | WI | MEDICAID | 200403240A | 05 | IN | MEDICAID | 32882300 | 05 | WI | MEDICAID | 0592394 | 05 | IA | MEDICAID | 32780900 | 05 | WI | MEDICAID | 5E293GR | 05 | MN | MEDICAID | 32824600 | 05 | WI | MEDICAID | 200232380A | 05 | IN | MEDICAID |