Provider Demographics
NPI:1194072660
Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Entity type:Organization
Organization Name:WATERTOWN REGIONAL MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR-PATIENT ACCOUNTING
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4784
Mailing Address - Street 1:PO BOX 684088
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60695-4088
Mailing Address - Country:US
Mailing Address - Phone:920-262-4784
Mailing Address - Fax:920-262-4640
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:STE 2002
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3320
Practice Address - Country:US
Practice Address - Phone:920-262-4460
Practice Address - Fax:920-262-4533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERTOWN REGIONAL MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-14
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100024938Medicaid
WI100024938Medicaid