Provider Demographics
NPI:1811944093
Name:ST. MARYS DEAN VENTURES INC.
Entity type:Organization
Organization Name:ST. MARYS DEAN VENTURES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
Mailing Address - Street 1:1305 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1503
Mailing Address - Country:US
Mailing Address - Phone:262-472-7686
Mailing Address - Fax:262-472-7691
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:888-968-4681
Practice Address - Fax:608-355-7001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-31
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QM1300X, 261QR0200X, 261QR0206X, 291U00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32829800Medicaid
IN200403240AMedicaid
WI32882300Medicaid
IA0592394Medicaid
WI32780900Medicaid
MN5E293GRMedicaid
WI32824600Medicaid
IN200232380AMedicaid
MN5E293GRMedicaid
WI32824600Medicaid
WI32780900Medicaid
WI000054375Medicare PIN
WI000013215Medicare PIN