Basic Information
| Provider Information | |||||||||
| NPI: | 1023022803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINNESHIEK MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | WINNESHIEK MEDICAL CENTER ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | DECORAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 521012325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | RADTKE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 5633873145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 869T2WI | 01 | MN | BLUE CROSS OF MN | OTHER | 0736561 | 05 | IA | MEDICAID | 23199 | 01 | IA | BLUE CROSS OF IOWA | OTHER |