Provider Demographics
NPI:1720029804
Name:WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC DBA WAUSHARA FAMILY PHYSICIA
Entity Type:Organization
Organization Name:WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC DBA WAUSHARA FAMILY PHYSICIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-622-5576
Mailing Address - Street 1:701 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-0243
Mailing Address - Country:US
Mailing Address - Phone:920-622-5560
Mailing Address - Fax:
Practice Address - Street 1:601 GROVE AVENUE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-0243
Practice Address - Country:US
Practice Address - Phone:920-622-5560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32829100Medicaid