1053859058 NPI number — INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.

Table of content: (NPI 1053859058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053859058 NPI number — INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INDIANHEAD MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053859058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELL LAKE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54871-0300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-468-7833
Provider Business Mailing Address Fax Number:
715-468-7303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7728 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIREN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54872-8041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-349-2910
Provider Business Practice Location Address Fax Number:
715-468-7303
Provider Enumeration Date:
02/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JACK
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
715-468-7833

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11020710 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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