Healthcare Provider Details

I. General information

NPI: 1992776041
Provider Name (Legal Business Name): WATERTOWN MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HOSPITAL DR
WATERTOWN WI
53098-3303
US

IV. Provider business mailing address

680 S 4TH ST
LOUISVILLE KY
40202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 920-261-4210
  • Fax:
Mailing address:
  • Phone: 502-596-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: JOHNETTA TRAYLOR
Title or Position: AO
Credential:
Phone: 502-596-6063