Provider Demographics
NPI:1275879884
Name:MILE BLUFF MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MILE BLUFF MEDICAL CENTER INC
Other - Org Name:MILE BLUFF CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:OKEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-6161
Mailing Address - Street 1:1040 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1931
Mailing Address - Country:US
Mailing Address - Phone:608-847-6161
Mailing Address - Fax:608-847-2079
Practice Address - Street 1:321 BUTTS AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1412
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:608-374-0355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILE BLUFF MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-31
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000057025Medicare PIN