Provider Demographics
NPI:1356824551
Name:TOMAH MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:TOMAH MEMORIAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PFS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-377-8650
Mailing Address - Street 1:321 BUTTS AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1412
Mailing Address - Country:US
Mailing Address - Phone:608-372-2181
Mailing Address - Fax:608-374-0287
Practice Address - Street 1:501 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-377-8650
Practice Address - Fax:608-377-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11017810Medicaid