Basic Information
| Provider Information | |||||||||
| NPI: | 1053710889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAUI MEMORIAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082433030 | ||||||||
| FaxNumber: | 8084425652 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082433030 | ||||||||
| FaxNumber: | 8084425652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2014 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | LO | ||||||||
| AuthorizedOfficialFirstName: | WESLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHEIF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8084425100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HAWAII HEALTH SYSTEMS CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | OHCA 3-H | HI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00005796 | 05 | HI | MEDICAID | H005187 | 01 | OUTPATIENT | OTHER | A005189 | 01 | QUEST INPATIENT | OTHER | C005185 | 01 | SNF ANCIL WAITLIST | OTHER | E005180 | 01 | OUTPATIENT OTHER | OTHER | P005186 | 01 | QUEST ICF ANCIL WAITLIST | OTHER | 120002 | 01 | MEDICARE ID - TYPE UNSPECIFIED | OTHER | G005186 | 01 | SNF FACILITY | OTHER |