Provider Demographics
NPI:1568552958
Name:ST CLARE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:ST CLARE MEMORIAL HOSPITAL, INC
Other - Org Name:ST CLARE MEMORIAL HOSPITAL MOUNTAIN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-884-5660
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 1:14353 HWY 32/64
Practice Address - Street 2:
Practice Address - City:MOUNTAIN
Practice Address - State:WI
Practice Address - Zip Code:54149
Practice Address - Country:US
Practice Address - Phone:715-276-1600
Practice Address - Fax:715-276-1800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLARE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23967-020207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316940927OtherGREMBAN NPI
WI1689677213OtherBOLLENBACH NPI
1851477913OtherCMH NPI
WI11014110Medicaid
WI1689677213OtherBOLLENBACH NPI
WI11014110Medicaid
WI528545Medicare Oscar/Certification