1093096224 NPI number — COMMUNITY MEMORIAL HOSPITAL, INCORPORATED

Table of content: (NPI 1093096224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093096224 NPI number — COMMUNITY MEMORIAL HOSPITAL, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
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:
Provider Other Organization Name Type Code:
6
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:
1093096224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25630 NETWORK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-1256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-360-3787
Provider Business Mailing Address Fax Number:
888-848-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1726 SHAWANO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54303-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-360-3787
Provider Business Practice Location Address Fax Number:
888-848-0225
Provider Enumeration Date:
09/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DEGROOT
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
920-846-3444

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  39597-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1851477913 . This is a "CMH NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1750302089 . This is a "PROVIDER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: WI2552 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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