Provider Demographics
NPI:1316102734
Name:HUDSON PHYSICIANS, S.C.
Entity type:Organization
Organization Name:HUDSON PHYSICIANS, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:GERI
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-531-6060
Mailing Address - Street 1:403 STAGELINE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7848
Mailing Address - Country:US
Mailing Address - Phone:715-531-6800
Mailing Address - Fax:715-531-6801
Practice Address - Street 1:2310 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9315
Practice Address - Country:US
Practice Address - Phone:715-531-6802
Practice Address - Fax:715-531-6803
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUDSON PHYSICIANS, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-24
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32723100Medicaid
WI000056125OtherMEDICARE