Provider Demographics
NPI:1467468173
Name:GUNDERSEN LUTHERAN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:GUNDERSEN LUTHERAN MEDICAL CENTER, INC.
Other - Org Name:GUNDERSEN AIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-8025
Mailing Address - Street 1:1910 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5467
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1900 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5467
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN LUTHERAN MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60013363416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41442400Medicaid
MN765347600Medicaid
IA0991679Medicaid
IA0991679Medicaid