Provider Demographics
NPI:1538491998
Name:BEAVER DAM COMMUNITY HOSPITALS INC
Entity Type:Organization
Organization Name:BEAVER DAM COMMUNITY HOSPITALS INC
Other - Org Name:(INACTIVE) MARSHFIELD MEDICAL CENTER - BEAVER DAM FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/COO/AO
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:T
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-387-5823
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT SERVICES/WWP
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-0660
Mailing Address - Fax:
Practice Address - Street 1:130 WARREN ST STE 132
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-7181
Practice Address - Fax:920-887-6833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHFIELD CLINIC HEALTH SYSTEM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-09
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI851-800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11012200Medicaid
WI000021104Medicare Oscar/Certification
WI11012200Medicaid