Provider Demographics
NPI:1578747580
Name:WATERTOWN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WATERTOWN REGIONAL MEDICAL CENTER INC
Other - Org Name:UWHP WRMC DOCTORS COURT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PATIENT ACCOUNTING
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:PO BOX 684088
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60695-4088
Mailing Address - Country:US
Mailing Address - Phone:920-262-4784
Mailing Address - Fax:
Practice Address - Street 1:1507 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4101
Practice Address - Country:US
Practice Address - Phone:920-262-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERTOWN REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-27
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21319400Medicaid
WI21319400Medicaid