Basic Information
| Provider Information | |||||||||
| NPI: | 1811256126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CROIX REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FREDERIC CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 WEST OAK STREET | ||||||||
| Address2: | |||||||||
| City: | FREDERIC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153275700 | ||||||||
| FaxNumber: | 7153275784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2012 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | YOUSO | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7154830556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1041 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.