Provider Demographics
NPI:1437253648
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:MENDOTA MENTAL HEALTH INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN RYBROECK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD JD
Authorized Official - Phone:608-301-1042
Mailing Address - Street 1:301 TROY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1521
Mailing Address - Country:US
Mailing Address - Phone:608-301-1000
Mailing Address - Fax:608-301-1390
Practice Address - Street 1:301 TROY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1521
Practice Address - Country:US
Practice Address - Phone:608-301-1000
Practice Address - Fax:608-301-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI283Q00000X282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10063400Medicaid
WI10063400Medicaid