Basic Information
| Provider Information | |||||||||
| NPI: | 1053859058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANHEAD MEDICAL CENTER SHELL LAKE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INDIANHEAD MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154687833 | ||||||||
| FaxNumber: | 7154687303 | ||||||||
| Practice Location | |||||||||
| Address1: | 7728 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIREN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548728041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153492910 | ||||||||
| FaxNumber: | 7154687303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACK | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7154687833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 11020710 | 05 | WI | MEDICAID |