Provider Demographics
NPI:1609275262
Name:MAUI MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MAUI MEMORIAL MEDICAL CENTER
Other - Org Name:MAUI MEMORIAL MEDICAL CENTER OUTPATIENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-442-5100
Mailing Address - Street 1:221 MAHALANI STREET
Mailing Address - Street 2:COTTAGE 18
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793
Mailing Address - Country:US
Mailing Address - Phone:808-243-3030
Mailing Address - Fax:808-442-5652
Practice Address - Street 1:85 MAUI LANI PARKWAY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-442-5700
Practice Address - Fax:808-442-5652
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAWAII HEALTH SYSTEMS CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00005796Medicaid
HIR36294(VA)Medicare UPIN
HIE10542(NE)Medicare UPIN
HIH43725(OK)Medicare UPIN
HI00005796Medicaid
HI106456Medicare UPIN
HIEF873ZMedicare UPIN
HIH103779(HI)Medicare UPIN
HI125054Medicare Oscar/Certification
HIB44816(MI)Medicare UPIN
HIR40761Medicare UPIN
HIF08508(NC)Medicare UPIN
HIED243YMedicare UPIN
HIBT583AMedicare PIN