Provider Demographics
NPI:1639187412
Name:LANGLADE HOSPITAL - HOTEL DIEU OF ST. JOSEPH OF ANTIGO WISCONSIN
Entity Type:Organization
Organization Name:LANGLADE HOSPITAL - HOTEL DIEU OF ST. JOSEPH OF ANTIGO WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2988
Mailing Address - Street 1:112 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2710
Mailing Address - Country:US
Mailing Address - Phone:715-623-2331
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 261QR0400X
WI1055282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41230700Medicaid
WI11018110Medicaid
WI11018100Medicaid
WI32765700Medicaid
WI11018110Medicaid
WI41230700Medicaid