MEDICARE: GRESHAM SCHOOL DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	44243500	OTHER	WI	SCHOOL BASED SERVICES

General Provider Information

NPI Number	:	1144418419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRESHAM SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	501 E SHABOW STREET
Second Line	:
City	:	GRESHAM
State	:	WI
Zip	:	53128-9505
Country	:	US
Telephone Number	:	715-787-3211
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 EAST SHABOW STREET
Second Line	:
City	:	GRESHAM
State	:	WI
Zip	:	53128-9505
Country	:	US
Telephone Number	:	715-787-3211
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS SERVICES
Name	:	HOLLY BURR
Credential	:
Telephone Number	:	715-787-3211

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	10/11/2007

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Directions to “GRESHAM SCHOOL DISTRICT ” Practice Location

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