Basic Information
Provider Information | |||||||||
NPI: | 1043397177 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AURORA MEDICAL CENTER BAY AREA, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | AURORA HEALTH CARE- PAYOR ACTIVATION | ||||||||
Address2: | 3301 W FOREST HOME AVE | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532152843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146476326 | ||||||||
FaxNumber: | 4143891509 | ||||||||
Practice Location | |||||||||
Address1: | 3003 UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | MARINETTE | ||||||||
State: | WI | ||||||||
PostalCode: | 541434110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7157351721 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 10/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | NAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4142991610 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 806019500 | 05 | ID |   | MEDICAID | 1719117 | 05 | LA |   | MEDICAID | 1711544TYPE40 | 05 | MI |   | MEDICAID | 2564336 | 05 | OH |   | MEDICAID | 1711526TYPE30 | 05 | MI |   | MEDICAID | ========= | 05 | IL |   | MEDICAID | 11001400 | 05 | WI |   | MEDICAID | 70255300 | 05 | MN |   | MEDICAID |