Provider Demographics
NPI:1215119706
Name:ST. LUKE'S HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:ST. LUKE'S HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-687-4886
Mailing Address - Street 1:PO BOX 681126
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53268-1126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-4285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========018OtherBLUE CROSS BLUE SHIELD