Provider Demographics
NPI:1033152939
Name:SSM HEALTH CARE OF WISCONSIN,INC
Entity Type:Organization
Organization Name:SSM HEALTH CARE OF WISCONSIN,INC
Other - Org Name:ST. MARY'S HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:STARMANN-HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-258-6121
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-251-6100
Mailing Address - Fax:608-258-5221
Practice Address - Street 1:2840 INDEX RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53713-3117
Practice Address - Country:US
Practice Address - Phone:608-229-7222
Practice Address - Fax:608-229-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI67OtherDEANCARE PROVIDER NUMBER
WI390806393026OtherBLUE CROSS PROV NUMBER
WI390806393OtherOTHER INS PROVIDER NUMBER
WI5389107OtherPHYSICIANS PLUS PROVIDER
WI11022900Medicaid
WI39080639301OtherUNITY PROVIDER NUMBER
WI5283846OtherMEDICA PROVIDER NUMBER
WIA5371501OtherJOHN DEERE PROVIDER NUMBE
WI=========009OtherTRICARE PROVIDER NUMBER
WIA5371501OtherJOHN DEERE PROVIDER NUMBE
IL=========002Medicaid