Provider Demographics
NPI:1437179231
Name:MEMORIAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER INC
Other - Org Name:TAMARACK HEALTH ASHLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-685-5512
Mailing Address - Street 1:1615 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-5500
Mailing Address - Fax:715-685-5118
Practice Address - Street 1:1615 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-5500
Practice Address - Fax:715-685-5118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1066273R00000X
WI1065282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11019510OtherMEDICAID - CAH
WI11019521Medicaid
WI00001048Medicaid
MI301555922Medicaid
MN36585MEOtherBCBS PROF COMPONENTS
MN0160JMEOtherBCBS BEH HEALTH INPT
WI32947500Medicaid
MN099847800Medicaid
WI11019500Medicaid
WI11019526Medicaid
WI32769900Medicaid
MI405172492Medicaid
WI32769900Medicaid
WI11019526Medicaid
WICD8476Medicare ID - Type UnspecifiedRR MEDICARE
WI000000250Medicare ID - Type UnspecifiedMEDICARE PART B
WI11019500Medicaid
MI301555922Medicaid