Provider Demographics
NPI:1477005544
Name:PRAIRIE RIDGE HEALTH, INC.
Entity Type:Organization
Organization Name:PRAIRIE RIDGE HEALTH, INC.
Other - Org Name:COLUMBUS COMMUNITY HOSPITAL, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-623-1368
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-0418
Mailing Address - Country:US
Mailing Address - Phone:608-655-8181
Mailing Address - Fax:608-655-8224
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9799
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:920-623-1441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBUS COMMUNITY HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-25
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21498-20261QP2300X
WI2985364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D2123598OtherCLIA NUMBER