Provider Demographics
NPI:1093096224
Name:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Other - Org Name:D/B/A BREAST SURGERY EXPERTS OF NORTHEAST WISCONSIN LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-846-3444
Mailing Address - Street 1:25630 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1256
Mailing Address - Country:US
Mailing Address - Phone:920-360-3787
Mailing Address - Fax:888-848-0225
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:920-360-3787
Practice Address - Fax:888-848-0225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-01
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39597-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851477913OtherCMH NPI
WI1750302089OtherPROVIDER
WIWI2552OtherMEDICARE PTAN