Provider Demographics
NPI:1760460877
Name:WAUPUN MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WAUPUN MEMORIAL HOSPITAL
Other - Org Name:SSM HEALTH DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-5402
Mailing Address - Street 1:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1283
Mailing Address - Country:US
Mailing Address - Phone:920-926-4472
Mailing Address - Fax:920-926-8885
Practice Address - Street 1:10 BEAVER DAM ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1869
Practice Address - Country:US
Practice Address - Phone:920-324-5581
Practice Address - Fax:920-926-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42052700OtherWI CHRONIC DISEASE PROGRA
WIZ3OtherDEAN CARE
WI42052700Medicaid
WI42052700OtherWI CHRONIC DISEASE PROGRA
522301Medicare Oscar/Certification