Healthcare Provider Details

I. General information

NPI: 1043499080
Provider Name (Legal Business Name): WATERTOWN REGIONAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 VILLAGE WALK LN
JOHNSON CREEK WI
53038-9554
US

IV. Provider business mailing address

PO BOX 684088
CHICAGO IL
60695-4088
US

V. Phone/Fax

Practice location:
  • Phone: 920-699-6200
  • Fax:
Mailing address:
  • Phone: 920-699-6200
  • Fax: 920-262-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: MR. ROBERT JAMES KLUGE
Title or Position: PATIENT ACCOUNTS MANAGER
Credential:
Phone: 920-262-4784