Provider Demographics
NPI:1003159195
Name:GUNDERSEN LUTHERAN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GUNDERSEN LUTHERAN MEDICAL CENTER INC
Other - Org Name:GLMC VIROQUA RENAL DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-8025
Mailing Address - Street 1:1910 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5467
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:407 S MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-4001
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN LUTHERAN MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-27
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042703Medicaid
WI523517Medicare Oscar/Certification