Provider Demographics
NPI:1770861965
Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Other - Org Name:WRMC URGENT CARE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR-PATIENT ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:PO BOX 684088
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60695-4088
Mailing Address - Country:US
Mailing Address - Phone:920-262-4422
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:SUITE 2004
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERTOWN REGIONAL MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-22
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100016949Medicaid
WI000030125Medicare PIN