Provider Demographics
NPI:1376532713
Name:MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:POLENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-743-3101
Mailing Address - Street 1:216 SUNSET PL
Mailing Address - Street 2:
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1706
Mailing Address - Country:US
Mailing Address - Phone:715-743-3101
Mailing Address - Fax:715-743-6245
Practice Address - Street 1:502 E ELM DR
Practice Address - Street 2:
Practice Address - City:LOYAL
Practice Address - State:WI
Practice Address - Zip Code:54446-9604
Practice Address - Country:US
Practice Address - Phone:715-255-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43051600Medicaid
WI43051600Medicaid