Provider Demographics
NPI:1760522452
Name:COLUMBIA CORRECTIONAL INSTITUTION
Entity Type:Organization
Organization Name:COLUMBIA CORRECTIONAL INSTITUTION
Other - Org Name:CCI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULIENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-742-9100
Mailing Address - Street 1:2925 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9485
Practice Address - Country:US
Practice Address - Phone:608-742-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28096261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center