Provider Demographics
NPI:1346353695
Name:WAUKESHA HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:WAUKESHA HEALTH SYSTEM, INC.
Other - Org Name:BEHAVIORAL MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:SYRJANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-928-2382
Mailing Address - Street 1:721 AMERICAN AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-2396
Mailing Address - Fax:262-544-1213
Practice Address - Street 1:721 AMERICAN AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-2396
Practice Address - Fax:262-544-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1976261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV42125500Medicaid
WV42125500Medicaid