Healthcare Provider Details

I. General information

NPI: 1912329335
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: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 PARK AVE
COLUMBUS WI
53925-2401
US

IV. Provider business mailing address

1511 PARK AVE
COLUMBUS WI
53925-2401
US

V. Phone/Fax

Practice location:
  • Phone: 920-623-2200
  • Fax:
Mailing address:
  • Phone: 920-623-1200
  • Fax: 920-623-1340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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