Provider Demographics
NPI:1881672004
Name:WAUPUN MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:WAUPUN MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-356-1423
Mailing Address - Street 1:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1283
Mailing Address - Country:US
Mailing Address - Phone:920-926-4472
Mailing Address - Fax:920-926-8885
Practice Address - Street 1:110 MONROE ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2437
Practice Address - Country:US
Practice Address - Phone:920-887-3376
Practice Address - Fax:920-887-3532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUPUN MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-06
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI567318OtherDEAN CARE
WI42059500OtherWI CHRONIC DISEASE PROGRA
WI42059500Medicaid
WI42059500Medicaid