Provider Demographics
NPI:1225003445
Name:SAUK PRAIRIE HEALTHCARE INC
Entity Type:Organization
Organization Name:SAUK PRAIRIE HEALTHCARE INC
Other - Org Name:LODI MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DREGNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-643-7212
Mailing Address - Street 1:160 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 VALLEY DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1464
Practice Address - Country:US
Practice Address - Phone:608-592-3296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI6108OtherRAILROAD MEDICARE
WI32764200Medicaid
WI32764200Medicaid
0752040001Medicare NSC
IL=========001OtherIL MEDICAID HFS