Healthcare Provider Details

I. General information

NPI: 1093137416
Provider Name (Legal Business Name): PRAIRIE RIDGE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 CORPORATE DR
BEAVER DAM WI
53916-3116
US

IV. Provider business mailing address

1515 PARK AVE
COLUMBUS WI
53925-2402
US

V. Phone/Fax

Practice location:
  • Phone: 920-356-1000
  • Fax:
Mailing address:
  • Phone: 920-623-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN RUSSELL
Title or Position: PRESIDENT & CEO
Credential:
Phone: 920-623-1368