Basic Information
| Provider Information | |||||||||
| NPI: | 1871656082 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION SETON DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860496 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145851000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2323 N LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142911000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | HANSELMAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4144653000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 111 | WI | N | Hospitals | General Acute Care Hospital | 282N00000X | 53 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 11010304 | 05 | WI | MEDICAID | 41223700 | 05 | WI | MEDICAID | 42197600 | 05 | WI | MEDICAID | 11010300 | 05 | WI | MEDICAID | 21294400 | 05 | WI | MEDICAID | 36200900 | 05 | WI | MEDICAID | 21295200 | 05 | WI | MEDICAID | 38396200 | 05 | WI | MEDICAID | 42197621 | 05 | WI | MEDICAID | 36200500 | 05 | WI | MEDICAID | 21292900 | 05 | WI | MEDICAID |