Basic Information
| Provider Information | |||||||||
| NPI: | 1043240922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CROIX REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOBOSENSKI | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7154830549 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 224Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225200000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QU0200X | 1041 | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282NC0060X | 1041 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 11015000 | 05 | WI | MEDICAID | 5006381 | 01 | WI | MEDICA | OTHER | 914 | 01 | WI | HEALTHPARTNERS | OTHER | CE8643 | 01 | WI | RR MEDICARE CLINIC | OTHER | 11015010 | 05 | WI | MEDICAID | 63Q99RI | 01 | MN | BCBS MN PROFESSIONAL CHGS | OTHER | E8643 | 01 | WI | RR MEDICARE HOSPITAL | OTHER | 1006064 | 01 | WI | PREFERRED ONE | OTHER | 196547600 | 05 | MN | MEDICAID |