Basic Information
Provider Information | |||||||||
NPI: | 1215085253 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLACK RIVER MEMORIAL HOSPITAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 711 W ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546159108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152845361 | ||||||||
FaxNumber: | 7152841398 | ||||||||
Practice Location | |||||||||
Address1: | 311 COUNTY ROAD A STE 1 | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546158205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152845361 | ||||||||
FaxNumber: | 7152841398 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2007 | ||||||||
LastUpdateDate: | 12/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITE-JACOBS | ||||||||
AuthorizedOfficialFirstName: | MARY BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 7152845361 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN BSN MHA FACHE | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 527298 | WI | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 41538200 | 05 | WI |   | MEDICAID |