Provider Demographics
NPI:1417120197
Name:REHABILITATION HOSPITAL OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:REHABILITATION HOSPITAL OF WISCONSIN, LLC
Other - Org Name:REHABILITATION HOSPITAL OF WISCONSIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-521-8801
Mailing Address - Street 1:1625 COLDWATER CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:262-744-0659
Mailing Address - Fax:636-730-3127
Practice Address - Street 1:1625 COLDWATER CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:314-881-4275
Practice Address - Fax:636-730-3127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI523027Medicare Oscar/Certification