Provider Demographics
NPI:1154403657
Name:PRAIRIE RIDGE HEALTH, INC.
Entity type:Organization
Organization Name:PRAIRIE RIDGE HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-623-8453
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2402
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:920-623-1441
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2402
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:920-623-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI278-800282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11012810Medicaid
WI36200200Medicaid
WIWI0105OtherJOHN DEERE CRNA
WV43414600Medicaid
WI32763600Medicaid
WIWI0100OtherJOHN DEERE EKG, RT
WI41172200Medicaid
WIWI0104OtherJOHN DEERE ER/UC
WI41172200Medicaid
WIWI0105OtherJOHN DEERE CRNA
WI21109Medicare ID - Type UnspecifiedANESTHESIA/CRNA
WI36200200Medicaid