Healthcare Provider Details

I. General information

NPI: 1245489897
Provider Name (Legal Business Name): WATERTOWN REGIONAL MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 09/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S CHURCH ST
WATERTOWN WI
53094-6213
US

IV. Provider business mailing address

125 HOSPITAL DR
WATERTOWN WI
53098-3303
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBERT J KLUGE
Title or Position: PATIENT FINANCIAL SERVICES MANAGER
Credential:
Phone: 920-262-4784