Provider Demographics
NPI:1801005210
Name:MEMORIAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER INC
Other - Org Name:TAMARACK HEALTH ASHLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-685-5512
Mailing Address - Street 1:1615 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-5500
Mailing Address - Fax:715-685-5118
Practice Address - Street 1:1615 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-5500
Practice Address - Fax:715-685-5118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2023-11-22
Deactivation Date:2008-02-01
Deactivation Code:
Reactivation Date:2008-09-10
Provider Licenses
StateLicense IDTaxonomies
WI275273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11019526Medicaid
MN0160HMEOtherBLUE CROSS BLUE SHIELD
WI3901638OtherMEDICA PROF COMPONENT
WI11019500Medicaid
WI01022385OtherPREFERRED ONE
MN0160JMEOtherBLUE CROSS BLUE SHIELD
WI11019521Medicaid
MN36585MEOtherBCBS PROF COMPONENT
WI5025472OtherMEDICA
MN0160JMEOtherBLUE CROSS BLUE SHIELD
WI01022385OtherPREFERRED ONE
WI11019521Medicaid
WI5025472OtherMEDICA
WI11019521Medicaid