Provider Demographics
NPI:1609841568
Name:SAUK PRAIRIE HEALTHCARE INC
Entity Type:Organization
Organization Name:SAUK PRAIRIE HEALTHCARE INC
Other - Org Name:RIVER VALLEY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DREGNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-643-7212
Mailing Address - Street 1:436 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-9286
Mailing Address - Country:US
Mailing Address - Phone:608-588-2502
Mailing Address - Fax:
Practice Address - Street 1:436 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9286
Practice Address - Country:US
Practice Address - Phone:608-588-2502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32764200Medicaid
CD3549OtherRAILROAD MEDICARE
WI43061900Medicaid
IL=========001OtherIL MEDICAID HFS
WI32764200Medicaid
000057065Medicare Oscar/Certification
WI43061900Medicaid