Provider Demographics
NPI:1063682938
Name:UW - LA CROSSE STUDENT HEALTH CENTER
Entity Type:Organization
Organization Name:UW - LA CROSSE STUDENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:608-785-8558
Mailing Address - Street 1:1300 BADGER ST
Mailing Address - Street 2:SUITE 1030
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-1502
Mailing Address - Country:US
Mailing Address - Phone:608-785-8558
Mailing Address - Fax:608-785-8746
Practice Address - Street 1:1300 BADGER ST
Practice Address - Street 2:SUITE 1030
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-1502
Practice Address - Country:US
Practice Address - Phone:608-785-8558
Practice Address - Fax:608-785-8746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28854261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31496500Medicaid
WIP19507Medicare UPIN
WIB56999Medicare UPIN
WID03155Medicare UPIN
WI31496500Medicaid