Basic Information
| Provider Information | |||||||||
| NPI: | 1851336044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPHS COMMUNITY HOSPITAL OF WEST BEND INC. | ||||||||
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| OtherOrganizationName: | FROEDTERT WEST BEND HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74W12501 LEATHERWOOD CT STE 103 | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147770417 | ||||||||
| FaxNumber: | 4147770096 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623345533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | ERICSON | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2628368391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 44 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 32946800 | 01 | WI | T19 REF LAB # | OTHER | 41664800 | 05 | WI | MEDICAID | 32770300 | 05 | WI | MEDICAID | 11011200 | 05 | WI | MEDICAID |