Healthcare Provider Details

I. General information

NPI: 1134194004
Provider Name (Legal Business Name): SAUK PRAIRIE HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MAIN ST
PLAIN WI
53577-9668
US

IV. Provider business mailing address

825 MAIN ST
PLAIN WI
53577-9668
US

V. Phone/Fax

Practice location:
  • Phone: 608-546-4211
  • Fax:
Mailing address:
  • Phone: 608-546-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier43062000
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 2
IdentifierCD3549
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier32764200
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: JAMES DREGNEY
Title or Position: CFO
Credential:
Phone: 608-643-7212