Healthcare Provider Details

I. General information

NPI: 1023310034
Provider Name (Legal Business Name): BEAVER DAM COMMUNITY HOSPITALS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S UNIVERSITY AVE STE 150
BEAVER DAM WI
53916
US

IV. Provider business mailing address

1000 N OAK AVE ATTN: PROVIDER ENROLLMENT SERVICES/WWP
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 920-219-4009
  • Fax: 920-219-9709
Mailing address:
  • Phone: 715-389-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GORDON T EDWARDS
Title or Position: CFO/COO/AO
Credential:
Phone: 715-387-5823