Provider Demographics
NPI:1225191687
Name:BURNETT MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BURNETT MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAUGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-463-7281
Mailing Address - Street 1:257 W SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7827
Mailing Address - Country:US
Mailing Address - Phone:715-463-5353
Mailing Address - Fax:715-463-2423
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7827
Practice Address - Country:US
Practice Address - Phone:715-463-5353
Practice Address - Fax:715-463-2423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1034282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN526247000Medicaid
MN124768Medicaid
MN300206Medicaid
WI32764700Medicaid
WI001212Medicaid
WI110166100Medicaid
WI20138900Medicaid
WI001212Medicaid
WI000000498Medicare ID - Type UnspecifiedMEDICARE WPS - CLINIC
WI528517Medicare ID - Type UnspecifiedCLINIC - RHC