Provider Demographics
NPI:1952841868
Name:COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS, INC
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS, INC
Other - Org Name:COMMUNITY MEMORIAL HOSPITAL FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:262-257-3019
Mailing Address - Street 1:N74W12501 LEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:414-777-0417
Mailing Address - Fax:
Practice Address - Street 1:W180N8000 TOWN HALL RD FL 4
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-532-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-27
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11011200Medicaid
WI11011200Medicaid