Basic Information
| Provider Information | |||||||||
| NPI: | 1821086034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATERTOWN REGIONAL MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIRECTIONS COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530983334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202624800 | ||||||||
| FaxNumber: | 9202624813 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530983334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202624800 | ||||||||
| FaxNumber: | 9202624813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLUGE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9202624784 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WATERTOWN REGIONAL MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 42169000 | 05 | WI | MEDICAID |