Provider Demographics
NPI:1457580862
Name:HOLY FAMILY MEMORIAL, INC.
Entity Type:Organization
Organization Name:HOLY FAMILY MEMORIAL, INC.
Other - Org Name:LAKESHORE NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-320-2300
Mailing Address - Street 1:333 REED AVE
Mailing Address - Street 2:PO BOX 963
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2087
Mailing Address - Country:US
Mailing Address - Phone:920-684-8895
Mailing Address - Fax:920-684-1384
Practice Address - Street 1:333 REED AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2087
Practice Address - Country:US
Practice Address - Phone:920-684-8895
Practice Address - Fax:920-684-1384
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY FAMILY MEMORIAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI244652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty