Healthcare Provider Details

I. General information

NPI: 1205223518
Provider Name (Legal Business Name): WATERTOWN REGIONAL MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W RACINE ST
JEFFERSON WI
53549-1048
US

IV. Provider business mailing address

125 HOSPITAL DR
WATERTOWN WI
53098-3303
US

V. Phone/Fax

Practice location:
  • Phone: 920-541-3513
  • Fax:
Mailing address:
  • Phone: 920-262-4784
  • Fax: 920-262-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT JAMES KLUGE
Title or Position: DIRECTOR PATIENT ACCOUNTING
Credential:
Phone: 920-262-4784