Provider Demographics
NPI:1467583278
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-846-3444
Mailing Address - Street 1:103 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-1117
Mailing Address - Country:US
Mailing Address - Phone:920-835-1144
Mailing Address - Fax:920-835-1145
Practice Address - Street 1:103 1ST ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1117
Practice Address - Country:US
Practice Address - Phone:920-835-1144
Practice Address - Fax:920-835-1145
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:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1515-23363A00000X
WI212-23363A00000X
WI25152-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477750644OtherNPI FOX
1851477913OtherCMH NPI
1760462352OtherNPI KNUTSON
1215024716OtherNPI BIRK
WI11014110Medicaid
1215024716OtherNPI BIRK
WI521310Medicare Oscar/Certification