Provider Demographics
NPI:1447397492
Name:MILE BLUFF MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MILE BLUFF MEDICAL CENTER INC
Other - Org Name:NECEDAH FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-6161
Mailing Address - Street 1:1408 WHEELIHAN AVE
Mailing Address - Street 2:
Mailing Address - City:NECEDAH
Mailing Address - State:WI
Mailing Address - Zip Code:54646-8253
Mailing Address - Country:US
Mailing Address - Phone:608-847-6161
Mailing Address - Fax:608-847-6161
Practice Address - Street 1:1408 WHEELIHAN AVE
Practice Address - Street 2:
Practice Address - City:NECEDAH
Practice Address - State:WI
Practice Address - Zip Code:54646-8253
Practice Address - Country:US
Practice Address - Phone:608-847-6161
Practice Address - Fax:608-847-6161
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILE BLUFF MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134261QR1300X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43054600Medicaid
WI=========Z6OtherUNITY PROVIDER NUMBER
=========OtherTAX ID NUMBER
WI=========Z7OtherUNITY PROVIDER NUMBER
WI43054600Medicaid
WI=========Z7OtherUNITY PROVIDER NUMBER
WI523990Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER