Provider Demographics
NPI:1801270962
Name:MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-743-8449
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:715-743-8022
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:715-743-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI641-23332900000X
WI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43051600Medicaid
WI523979Medicare Oscar/Certification