Provider Demographics
NPI:1134250905
Name:ST CLARE MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:ST CLARE MEMORIAL HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-884-5660
Mailing Address - Street 1:855 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:920-846-3444
Mailing Address - Fax:920-846-0250
Practice Address - Street 1:340 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9325
Practice Address - Country:US
Practice Address - Phone:920-855-2823
Practice Address - Fax:920-855-6343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLARE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38713-020207Q00000X
363LF0000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851477913OtherCMH NPI
WI11014110Medicaid
WI1639340995OtherBOUCHER NPI
WI1710966288OtherMALTINSKI NPI
WIG57206Medicare UPIN
WI11014110Medicaid
1851477913OtherCMH NPI
WI521310Medicare Oscar/Certification
WI00439Medicare PIN