Basic Information
| Provider Information | |||||||||
| NPI: | 1366420531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 791 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530663844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282510 | ||||||||
| FaxNumber: | 2629284032 | ||||||||
| Practice Location | |||||||||
| Address1: | 791 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282510 | ||||||||
| FaxNumber: | 2629284032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2629282263 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 113 | WI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 11011100 | 05 | WI | MEDICAID |