Provider Demographics
NPI:1629302831
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:COMMUNITY MEMORIAL HOSPITAL SOCIAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN DORNICK
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 1:855 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-3444
Practice Address - Fax:920-846-0250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-22
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7421-1231041C0700X
WI6699-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346393287OtherWINIUS NPI
WI1851477913OtherCMH NPI
WI1922270693OtherFLETCHER NPI
WI11014110Medicaid
WI1326349135OtherCMH SB NPI
WI00439Medicare PIN
WI1326349135OtherCMH SB NPI
WI1922270693OtherFLETCHER NPI