Basic Information
| Provider Information | |||||||||
| NPI: | 1063516078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK RIVER MEMORIAL HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152845361 | ||||||||
| FaxNumber: | 7152841390 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 COUNTY ROAD A STE 1 | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546158205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152845361 | ||||||||
| FaxNumber: | 7152841390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | WHITE-JACOBS | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7152845361 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN BSN MHA FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 1037 | WI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 43189700 | 05 | WI | MEDICAID |