Provider Demographics
NPI:1669463832
Name:OAK LEAF SURGICAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:OAK LEAF SURGICAL HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1000 OAKLEAF WAY
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2246
Mailing Address - Country:US
Mailing Address - Phone:715-831-8130
Mailing Address - Fax:715-839-1737
Practice Address - Street 1:1000 OAKLEAF WAY
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2246
Practice Address - Country:US
Practice Address - Phone:715-831-8130
Practice Address - Fax:715-839-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
WI8124-042284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI520196Medicare ID - Type Unspecified