Provider Demographics
NPI:1780646513
Name:BELLIN MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:BELLIN MEMORIAL HOSPITAL INC
Other - Org Name:FMC EAST DEPERE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:K
Authorized Official - Last Name:STROOBANTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-433-7864
Mailing Address - Street 1:555 REDBIRD CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7977
Mailing Address - Country:US
Mailing Address - Phone:920-338-6870
Mailing Address - Fax:
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLIN MEMORAIL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-05
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21260800Medicaid
WI21260800Medicaid
WI000007355Medicare Oscar/Certification
WI000080030Medicare Oscar/Certification