Provider Demographics
NPI:1407908189
Name:SWEDISHAMERICAN HOSPITAL
Entity Type:Organization
Organization Name:SWEDISHAMERICAN HOSPITAL
Other - Org Name:SA DAVIS JUNCTION CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-966-2084
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5665 N JUNCTION WAY
Practice Address - Street 2:
Practice Address - City:DAVIS JUNCTION
Practice Address - State:IL
Practice Address - Zip Code:61020
Practice Address - Country:US
Practice Address - Phone:779-696-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCLIAOther14D0990463
ILCLIAOther14D0990463
IL436860Medicare PIN
IL=========028OtherTRICARE