Basic Information
| Provider Information | |||||||||
| NPI: | 1982701397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH'S COMMUNITY HOSPITAL OF WEST BEND INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE KATHY HOSPICE AT ST. JOSEPH'S HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3232 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623345533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3232 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623345533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN DE KREEK | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4147770968 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOSEPH'S COMMUNITY HOSPITAL OF WEST BEND INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 315D00000X | Y | Nursing & Custodial Care Facilities | Hospice, Inpatient |
ID Information
| ID | Type | State | Issuer | Description | 43190500 | 05 | WI | MEDICAID | 000000243 | 01 | WI | MEDICARE PART B | OTHER |