Healthcare Provider Details

I. General information

NPI: 1811944093
Provider Name (Legal Business Name): ST. MARYS DEAN VENTURES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 TUTTLE ST
BARABOO WI
53913-3319
US

IV. Provider business mailing address

1305 W MAIN ST
WHITEWATER WI
53190-1503
US

V. Phone/Fax

Practice location:
  • Phone: 888-968-4681
  • Fax: 608-355-7001
Mailing address:
  • Phone: 262-472-7686
  • Fax: 262-472-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateWI

VIII. Authorized Official

Name: AMY J GRINNELL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 608-260-3586