Provider Demographics
NPI:1548437155
Name:CRIVITZ MEDICAL CENTER
Entity type:Organization
Organization Name:CRIVITZ MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUARTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2075
Mailing Address - Street 1:218 S HWY 141
Mailing Address - Street 2:
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114-1677
Mailing Address - Country:US
Mailing Address - Phone:715-854-7477
Mailing Address - Fax:715-854-7785
Practice Address - Street 1:213 S HWY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114
Practice Address - Country:US
Practice Address - Phone:715-732-2075
Practice Address - Fax:715-732-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43060400Medicaid
WI43060400Medicaid