Provider Demographics
NPI:1437470572
Name:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Other - Org Name:CMH PHYSICAL THERAPY - OCONTO
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
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:920-846-3444
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:920-846-3444
Mailing Address - Fax:920-846-0250
Practice Address - Street 1:103 1ST ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1117
Practice Address - Country:US
Practice Address - Phone:920-835-1144
Practice Address - Fax:920-835-1145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-11
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11014110Medicaid
1851477913OtherCMH NPI
1851477913OtherCMH NPI
WI00439Medicare PIN