Provider Demographics
NPI:1659899078
Name:INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Entity Type:Organization
Organization Name:INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Other - Org Name:INDIANHEAD MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-468-7833
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0300
Mailing Address - Country:US
Mailing Address - Phone:715-468-7833
Mailing Address - Fax:
Practice Address - Street 1:113 4TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-4457
Practice Address - Country:US
Practice Address - Phone:715-468-7833
Practice Address - Fax:715-468-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11020700Medicaid