Provider Demographics
NPI:1124083894
Name:DIVINE SAVIOR HEALTHCARE, INC.
Entity type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2988
Mailing Address - Street 1:29980 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1299
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-742-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QP2000X, 282N00000X
WI3729800282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11009500Medicaid
WI1023054137OtherINDIVIDUAL PHYSICIAN NPI
WI1073596235OtherINDIVIDUAL PHYSICIAN NPI
WI1619966058OtherINDIVIDUAL PHYSICIAN NPI
WI1457334468OtherINDIVIDUAL PHYSICIAN NPI
WI1174508261OtherINDIVIDUAL PHYSICIAN NPI
WV1437132669OtherINDIVIDUAL PHYSICIAN NPI
WI1699959593OtherINDIVIDUAL PHYSICIAN NPI
WI1336122506OtherINDIVIDUAL PHYSICIAN NPI
WI1376527002OtherINDIVIDUAL PHYSICIAN NPI
WI1659589653OtherINDIVIDUAL PHYSICIAN NPI
WI1871576017OtherINDIVIDUAL PHYSICIAN NPI
WI1144203381OtherINDIVIDUAL PHYSICIAN NPI
WI1497738637OtherINDIVIDUAL PHYSICIAN NPI
WI1537142765OtherINDIVIDUAL PHYSICIAN NPI
WI1689657827OtherINDIVIDUAL PHYSICIAN NPI
WI1881677011OtherINDIVIDUAL PHYSICIAN NPI
WI1619966058OtherINDIVIDUAL PHYSICIAN NPI
WI00230Medicare PIN
WV1437132669OtherINDIVIDUAL PHYSICIAN NPI