Provider Demographics
NPI:1720202864
Name:BEAVER DAM COMMUNITY HOSPITALS INC
Entity Type:Organization
Organization Name:BEAVER DAM COMMUNITY HOSPITALS INC
Other - Org Name:(INACTIVE) HILLSIDE UNIT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/COO/AO
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:T
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-387-5823
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT SERVICES/WWP
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-0660
Mailing Address - Fax:
Practice Address - Street 1:707 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3027
Practice Address - Country:US
Practice Address - Phone:920-887-4146
Practice Address - Fax:920-887-6613
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHFIELD CLINIC HEALTH SYSTEM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5344-042282N00000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5344-042OtherSTATE LICENSE #
WI5111923OtherNABP NUMBER
WI5111923OtherWI MEDICAID NUMBER
WIAB5024322OtherDEA #