Provider Demographics
NPI:1467435214
Name:SSM HEALTH CARE OF WISCONSIN INC
Entity Type:Organization
Organization Name:SSM HEALTH CARE OF WISCONSIN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-356-1400
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1539
Mailing Address - Country:US
Mailing Address - Phone:608-356-1400
Mailing Address - Fax:
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1539
Practice Address - Country:US
Practice Address - Phone:608-356-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH ST CLARE HOSPITAL-BARABOO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-25
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391023846OtherCOMMERICAL INS PROV #
WI1009390OtherPHYS PLUS PROV #
WI11022800Medicaid
WI391023846028OtherBLUE CROSS PROV #
WI000071014Medicare ID - Type UnspecifiedPART B MEDICARE PROV #