Basic Information
| Provider Information | |||||||||
| NPI: | 1699003202 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERY REGIONAL MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMERY HOSPITAL & CLINIC - BEHAVIORAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | 7152680261 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 DERONDA ST | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | 7152680071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUDQUIST | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7152688000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 528516 RHC | WI | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 273R00000X | 1069 | WI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 528516 | 01 | WI | RURAL HEALTH CLINIC LUCK CLINIC | OTHER |