Provider Demographics
NPI:1407801236
Name:CMH MOUNTAIN PRIMARY CARE CLINIC
Entity Type:Organization
Organization Name:CMH MOUNTAIN PRIMARY CARE CLINIC
Other - Org Name:DOUGLAS C GREMBAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:HENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-846-3440
Mailing Address - Street 1:855 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13435 WELLER RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN
Practice Address - State:WI
Practice Address - Zip Code:54149-9482
Practice Address - Country:US
Practice Address - Phone:715-276-1600
Practice Address - Fax:715-276-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23967020332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31756500Medicaid
5128904OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5128904OtherOTHER ID NUMBER