Provider Demographics
NPI:1679746747
Name:MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:POLENZ
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:715-743-3101
Mailing Address - Street 1:216 SUNSET PL
Mailing Address - Street 2:MEMORIAL HOSPITAL, INC
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1706
Mailing Address - Country:US
Mailing Address - Phone:715-743-3101
Mailing Address - Fax:715-743-6245
Practice Address - Street 1:216 SUNSET PL
Practice Address - Street 2:MEMORIAL HOSPITAL, INC
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1706
Practice Address - Country:US
Practice Address - Phone:715-743-3101
Practice Address - Fax:715-743-6245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32947200Medicaid
WI32947200Medicaid