Provider Demographics
NPI:1326030974
Name:WAGNER COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WAGNER COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:WAGNER COMMUNITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLABA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-384-3611
Mailing Address - Street 1:513 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-9675
Mailing Address - Country:US
Mailing Address - Phone:605-384-3611
Mailing Address - Fax:605-384-3232
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:605-384-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10571282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0100490Medicaid
SD9580610Medicaid
SD5500490Medicaid
SD4997772OtherWELLMARK CRNA
SD5800140Medicaid
SD81315OtherBLUE CROSS
SDS173Medicare PIN
SD9580610Medicaid
SD81315OtherBLUE CROSS
SD431315Medicare Oscar/Certification
SD5800140Medicaid