Provider Demographics
NPI:1619069630
Name:ST. CROIX VALLEY SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:ST. CROIX VALLEY SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-294-4898
Mailing Address - Street 1:204 3RD AVENUE
Mailing Address - Street 2:PO BOX 597
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0597
Mailing Address - Country:US
Mailing Address - Phone:715-294-4898
Mailing Address - Fax:
Practice Address - Street 1:204 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-0597
Practice Address - Country:US
Practice Address - Phone:715-294-4898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38459208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32892400Medicaid
WI38459OtherWISCONSIN LICENSE
MN36163OtherMINNESOTA LICENSE
WI32892400Medicaid
WI38459OtherWISCONSIN LICENSE