Provider Demographics
NPI:1043499080
Name:WATERTOWN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WATERTOWN REGIONAL MEDICAL CENTER INC
Other - Org Name:UWHP WRMC JOHNSON CREEK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT ACCOUNTS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:PO BOX 684088
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60695-4088
Mailing Address - Country:US
Mailing Address - Phone:920-699-6200
Mailing Address - Fax:920-262-4640
Practice Address - Street 1:540 VILLAGE WALK LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9554
Practice Address - Country:US
Practice Address - Phone:920-699-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERTOWN REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-26
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
WI=========261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21267000Medicaid
WI000030125Medicare PIN