Provider Demographics
NPI:1679558647
Name:STOUGHTON HOSPITAL ASSOCIATION
Entity type:Organization
Organization Name:STOUGHTON HOSPITAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-873-2250
Mailing Address - Street 1:900 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1864
Mailing Address - Country:US
Mailing Address - Phone:608-873-6611
Mailing Address - Fax:608-873-2255
Practice Address - Street 1:900 RIDGE ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1864
Practice Address - Country:US
Practice Address - Phone:608-873-6611
Practice Address - Fax:608-873-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-11-13
Deactivation Date:2015-11-06
Deactivation Code:
Reactivation Date:2015-11-19
Provider Licenses
StateLicense IDTaxonomies
WI3804800282NC0060X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11007210Medicaid
WI78OtherDEAN HEALTH PLAN
WI1009393OtherPHYSICIANS PLUS HEALTH IN
WI11007200Medicaid
WI11007200Medicaid
WI52M343Medicare ID - Type UnspecifiedGERO PSYCH
WI11007210Medicaid