NPIMap

Organization Active NPI

State of Wisconsin

Doing business as Southern Wisconsin Center

  • Intellectual Disabilities Intermediate Care Facility
  • Union Grove, WI
National Provider Identifier
1043326747
Registry record updated Feb 14, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
2763 Issued in WI
Legal business name
STATE OF WISCONSIN
Doing business as
Southern Wisconsin Center
Practice address
21425 Spring St
Union Grove, WI 53182-9707
Phone
(262) 878-2411
Fax
(262) 878-2922
NPI assigned
Aug 22, 2006
Last updated
Feb 14, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 14, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. James E Hutchison
Title
Nursing Home Administrator
Phone
(262) 878-2411

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 2763 WI Primary

Addresses

Primary practice location

21425 Spring St
Union Grove, WI 53182-9707

Mailing address

21425 Spring St
Union Grove, WI 53182-9707
Phone (262) 878-2411

Other identifiers 1

IdentifierTypeStateIssuer
21050000MedicaidWI

Other names 1

  • Southern Wisconsin Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050214000153 WI Part B Supplier - Clinic/Group Practice 9234181751 Receives reassigned benefits from 19 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Madison, WI; Winnebago, WI; Union Grove, WI; Chippewa Falls, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043326747. Details of each certification follow.

  • CCN 52G024 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 52G024

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
SOUTHERN WI CTR FDD
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Apr 1, 1983
Last certification
Jul 10, 2024
Beds
130
Ownership / control type
State
Most recent change of ownership
Apr 20, 2017
Facility address
21425 Spring St
Union Grove, WI 53182

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D0879904Southern Wisconsin Center21425 Spring St, Union Grove, WI 53182Certificate of waiverDec 2, 2027

National Provider Directory

National Provider Directory
Tax ID family
Winnebago Mental Health Institute4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156204800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202947200000",
    "number": "1043326747",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21425 SPRING ST",
            "city": "UNION GROVE",
            "state": "WI",
            "postal_code": "531829707",
            "telephone_number": "262-878-2411",
            "fax_number": "262-878-2922"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21425 SPRING ST",
            "city": "UNION GROVE",
            "state": "WI",
            "postal_code": "531829707",
            "telephone_number": "262-878-2411",
            "fax_number": "262-878-2922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF WISCONSIN",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-22",
        "last_updated": "2008-02-14",
        "status": "A",
        "authorized_official_last_name": "HUTCHISON",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "NURSING HOME ADMINISTRATOR",
        "authorized_official_telephone_number": "262-878-2411",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "WI",
            "license": "2763",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "21050000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southern Wisconsin Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Union Grove, WI

Sources for this page

Verify at the official NPI Registry.