Provider Demographics
NPI:1710939533
Name:MOUNDVIEW MEMORIAL HOSPITAL & CLINICS, INC
Entity Type:Organization
Organization Name:MOUNDVIEW MEMORIAL HOSPITAL & CLINICS, INC
Other - Org Name:GUNDERSEN MOUNDVIEW HOSPITAL AND CLINICS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ-GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-339-6814
Mailing Address - Street 1:402 W LAKE ST
Mailing Address - Street 2:PO BOX 40
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9699
Mailing Address - Country:US
Mailing Address - Phone:608-339-3331
Mailing Address - Fax:
Practice Address - Street 1:402 W LAKE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9699
Practice Address - Country:US
Practice Address - Phone:608-339-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI107800282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100002609Medicaid
WI21126600Medicaid
WI43061300Medicaid
WI41348000Medicaid
CR0660OtherMEDICARE RAILROAD
WI32764400Medicaid
WI36200100Medicaid
WI41231200Medicaid
WI11012010Medicaid
WI11012000Medicaid
WI20126600Medicaid
WI33121200Medicaid
WI41113800Medicaid
WI43061300Medicaid
WI32764400Medicaid