Provider Demographics
NPI:1902062540
Name:THE MONROE CLINIC, INC.
Entity Type:Organization
Organization Name:THE MONROE CLINIC, INC.
Other - Org Name:SSM HEALTH MONROE CLINIC NURSING HOME PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ILGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-324-1454
Mailing Address - Street 1:515 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 22ND AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1569
Practice Address - Country:US
Practice Address - Phone:608-324-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MONROE CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-04
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3771-0423336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33175600Medicaid
000086761Medicare PIN
WI000086761Medicare PIN