Provider Demographics
NPI:1780636480
Name:GUNDERSEN CLINIC, LTD.
Entity Type:Organization
Organization Name:GUNDERSEN CLINIC, LTD.
Other - Org Name:GL INDEPENDENCE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-8025
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:35791 OSSEO RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:WI
Practice Address - Zip Code:54747-9096
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43062500Medicaid
WI0233450008Medicare NSC
WI43062500Medicaid