Provider Demographics
NPI:1396806659
Name:EDGERTON HOSPITAL AND HEALTH SERVICES
Entity type:Organization
Organization Name:EDGERTON HOSPITAL AND HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-884-1656
Mailing Address - Street 1:11101 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-3441
Mailing Address - Fax:608-884-1669
Practice Address - Street 1:11101 N SHERMAN RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9002
Practice Address - Country:US
Practice Address - Phone:608-884-3441
Practice Address - Fax:608-884-1669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGERTON HOSPITAL AND HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1022275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52Z319Medicare Oscar/Certification