Provider Demographics
NPI:1992776041
Name:WATERTOWN MEDICAL CENTER LLC
Entity type:Organization
Organization Name:WATERTOWN MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT VICE PRESIDENT, SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-262-4784
Mailing Address - Fax:920-262-4640
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-261-4210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEPOINT HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-27
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11015400Medicaid
WI36202000Medicaid
WI40428200Medicaid
WI40428200Medicaid
WI520116Medicare Oscar/Certification