Provider Demographics
NPI:1467560227
Name:LADD MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:LADD MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:FORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-294-5622
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0218
Mailing Address - Country:US
Mailing Address - Phone:715-294-2111
Mailing Address - Fax:715-294-5696
Practice Address - Street 1:2600 65TH AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-4370
Practice Address - Country:US
Practice Address - Phone:715-294-2111
Practice Address - Fax:715-294-5696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC0050X
WI1021282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11018810Medicaid
WI11018800Medicaid
WI521318Medicare ID - Type Unspecified
WI00440Medicare ID - Type Unspecified
WI11018800Medicaid
WI11018810Medicaid