Provider Demographics
NPI:1679534697
Name:WESTERN WISCONSIN MEDICAL ASSOCIATES HUDSON LTD
Entity Type:Organization
Organization Name:WESTERN WISCONSIN MEDICAL ASSOCIATES HUDSON LTD
Other - Org Name:HUDSON PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-531-6800
Mailing Address - Street 1:403 STAGELINE ROAD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-531-6800
Mailing Address - Fax:715-531-6801
Practice Address - Street 1:403 STAGELINE ROAD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-531-6800
Practice Address - Fax:715-531-6801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WISCONSIN MEDICAL ASSOCIATES HUDSON LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-29
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QM1300X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32723100Medicaid
WI56125OtherMEDICARE
WI32723100Medicaid