NPI |
1396412441 |
The 10-position telephone number of the authorized official. |
Entity Type Code |
2 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Employer Identification Number EIN |
|
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Organization Name Legal Business Name |
GUNDERSEN CLINIC LTD |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Other Organization Name |
GHS ONALASKA YMCA PT OT |
Other name by which the organization provider is or has been known. |
Provider Other Organization Name Type Code |
5 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider First Line Business Practice Location Address |
400 MASON ST STE 200 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
ONALASKA |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
WI |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
546507032 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Provider Business Practice Location Address Country Code If outside U S |
US |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Provider Business Practice Location Address Telephone Number |
6087829622 |
|
Provider Enumeration Date |
8/26/2021 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Last Update Date |
6/14/2022 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Authorized Official Last Name |
ADANK |
|
Authorized Official First Name |
KARI |
|
Authorized Official Middle Name |
B |
The middle name of the authorized official. |
Authorized Official Title or Position |
CCO |
The title or position of the authorized official. |
Authorized Official Telephone Number |
6087758025 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
261Q00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
Y |
|
Parent Organization LBN |
GUNDERSEN CLINIC LTD |
|
Parent Organization TIN |
|
|
NPI Certification Date |
6/14/2022 |
|