MEDICARE: GUNDERSEN CLINIC, LTD.

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	261QR1300X	Rural Health Clinic/Center
2	261Q00000X	Clinic/Center		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336190941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUNDERSEN CLINIC, LTD.

Provider Business Mailing Address
First Line	:	1836 SOUTH AVE
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-5429
Country	:	US
Telephone Number	:	608-782-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 S PETERSON AVE
Second Line	:
City	:	BLAIR
State	:	WI
Zip	:	54616-8861
Country	:	US
Telephone Number	:	608-782-7300
Fax Number	:

Authorized Official
Title or Position	:	CCO
Name	:	KARI B ADANK
Credential	:
Telephone Number	:	608-775-8025

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	03/07/2016

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