Provider Demographics
NPI:1417316738
Name:ST. CLARE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:ST. CLARE MEMORIAL HOSPITAL, INC
Other - Org Name:HSHS SCO REGIONAL SURGERY CENTER OCONTO FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-846-4581
Mailing Address - Street 1:835 S MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:920-965-7411
Mailing Address - Fax:
Practice Address - Street 1:835 S MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-965-7411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. CLARE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-15
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI521310Medicare Oscar/Certification
WI00439Medicare PIN