Provider Demographics
NPI:1871837567
Name:GUNDERSEN LUTHERAN MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:GUNDERSEN LUTHERAN MEDICAL CENTER, INC
Other - Org Name:GLMC ONALASKA ANNEX BH
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 1:1910 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5467
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:123 16TH AVE S
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-3109
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN LUTHERAN MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42212400Medicaid
IA0699017Medicaid
MN765347600Medicaid
WI11012926Medicaid
WI11012900Medicaid
WI42194300Medicaid
WI11012900Medicaid