Basic Information
Provider Information | |||||||||
NPI: | 1871837567 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GUNDERSEN LUTHERAN MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GLMC ONALASKA ANNEX BH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1910 SOUTH AVE | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546015467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087827300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 123 16TH AVE S | ||||||||
Address2: |   | ||||||||
City: | ONALASKA | ||||||||
State: | WI | ||||||||
PostalCode: | 546503109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087827300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2012 | ||||||||
LastUpdateDate: | 03/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADANK | ||||||||
AuthorizedOfficialFirstName: | KARI | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | CCO | ||||||||
AuthorizedOfficialTelephone: | 6087758025 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GUNDERSEN LUTHERAN MEDICAL CENTER, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 42212400 | 05 | WI |   | MEDICAID | 0699017 | 05 | IA |   | MEDICAID | 765347600 | 05 | MN |   | MEDICAID | 11012926 | 05 | WI |   | MEDICAID | 11012900 | 05 | WI |   | MEDICAID | 42194300 | 05 | WI |   | MEDICAID |