Provider Demographics
NPI:1386819985
Name:MEMORIAL HOSPITAL OF BOSCOBEL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF BOSCOBEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-375-6213
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-4112
Mailing Address - Fax:
Practice Address - Street 1:205 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1642
Practice Address - Country:US
Practice Address - Phone:608-375-4112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSITAL OF BOSCOBEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
32945600OtherMEDICAID RURAL HEALTH