Provider Demographics
NPI: | 1093704447 |
---|---|
Name: | MEMORIAL HOSPITAL, INC. |
Entity Type: | Organization |
Organization Name: | MEMORIAL HOSPITAL, INC. |
Other - Org Name: | HOME HEALTH |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SCOTT |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | POLENZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 715-743-3101 |
Mailing Address - Street 1: | 216 SUNSET PL |
Mailing Address - Street 2: | |
Mailing Address - City: | NEILLSVILLE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54456-1706 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 715-743-3101 |
Mailing Address - Fax: | 715-743-6245 |
Practice Address - Street 1: | 216 SUNSET PL |
Practice Address - Street 2: | |
Practice Address - City: | NEILLSVILLE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54456-1706 |
Practice Address - Country: | US |
Practice Address - Phone: | 715-743-3101 |
Practice Address - Fax: | 715-743-3101 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-10-18 |
Last Update Date: | 2008-05-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 41512600 | Medicaid | |
WI | 41512600 | Medicaid |