Provider Demographics
NPI:1386705655
Name:STATE OF WISCONSIN
Entity type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTON
Authorized Official - Middle Name:O
Authorized Official - Last Name:SCHALICK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:609-301-9231
Mailing Address - Street 1:317 KNUTSON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1133
Mailing Address - Country:US
Mailing Address - Phone:608-301-9200
Mailing Address - Fax:608-301-1811
Practice Address - Street 1:317 KNUTSON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1133
Practice Address - Country:US
Practice Address - Phone:608-301-9200
Practice Address - Fax:608-301-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2780320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21050100Medicaid