Provider Demographics
NPI:1811939911
Name:MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INC.
Entity type:Organization
Organization Name:MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ-GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-339-6814
Mailing Address - Street 1:402 W LAKE ST
Mailing Address - Street 2:P.O. BOX 40
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9699
Mailing Address - Country:US
Mailing Address - Phone:608-339-8367
Mailing Address - Fax:608-339-8330
Practice Address - Street 1:402 W LAKE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9699
Practice Address - Country:US
Practice Address - Phone:608-339-8367
Practice Address - Fax:608-339-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI5181-423336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33121200Medicaid
2112711OtherPK