Provider Demographics
NPI:1740306992
Name:WAGNER COMMUNITY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:WAGNER COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUS. OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOUPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-384-3611
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-0280
Mailing Address - Country:US
Mailing Address - Phone:605-384-3418
Mailing Address - Fax:605-384-5240
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3418
Practice Address - Fax:605-384-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10571207Q00000X, 363A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS5877OtherMEDICARE GROUP
SD1008854Medicaid