Provider Demographics
NPI:1003146929
Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Other - Org Name:UWHP WRMC CENTER FOR EYE CARE - JOHNSON CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT FINANCIAL SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-262-4784
Mailing Address - Fax:920-262-4640
Practice Address - Street 1:540 VILLAGE WALK LN
Practice Address - Street 2:STE G
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9554
Practice Address - Country:US
Practice Address - Phone:920-699-4388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERTOWN REGIONAL MEDICAL CENTER, NNC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-29
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
WI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100007050Medicaid
WI100007050Medicaid