Provider Demographics
NPI:1750467098
Name:PRAIRIE RIDGE HEALTH, INC.
Entity Type:Organization
Organization Name:PRAIRIE RIDGE HEALTH, INC.
Other - Org Name:COLUMBUS COMMUNITY HOSPITAL, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-623-1368
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2402
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:920-623-1441
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2402
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:920-623-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI278-800275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52Z338Medicare Oscar/Certification