Provider Demographics
NPI:1356499784
Name:BURNETT MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BURNETT MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAUGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-463-7281
Mailing Address - Street 1:257 W SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7827
Mailing Address - Country:US
Mailing Address - Phone:715-463-5317
Mailing Address - Fax:
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7827
Practice Address - Country:US
Practice Address - Phone:715-463-5317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BURNETT MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1034207Q00000X, 363A00000X, 363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124768Medicaid
WI001212Medicaid
MN526247000Medicaid
WI110166100Medicaid
WI000009035Medicare ID - Type Unspecified
WI110166100Medicaid
WI001212Medicaid
WI528517Medicare ID - Type Unspecified