Basic Information
| Provider Information | |||||||||
| NPI: | 1437179231 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7156855512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 1066 | WI | N | Hospital Units | Psychiatric Unit | 282NC0060X | 1065 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0160JME | 01 | MN | BCBS BEH HEALTH INPT | OTHER | 11019510 | 01 | WI | MEDICAID - CAH | OTHER | 11019526 | 05 | WI | MEDICAID | 32947500 | 05 | WI | MEDICAID | 099847800 | 05 | MN | MEDICAID | 405172492 | 05 | MI | MEDICAID | 00001048 | 05 | WI | MEDICAID | 11019500 | 05 | WI | MEDICAID | 32769900 | 05 | WI | MEDICAID | 301555922 | 05 | MI | MEDICAID | 36585ME | 01 | MN | BCBS PROF COMPONENTS | OTHER | 11019521 | 05 | WI | MEDICAID |