Basic Information
| Provider Information | |||||||||
| NPI: | 1477653889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINSLOW MEMORIAL HOSPITAL INC | ||||||||
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| OtherOrganizationName: | LITTLE COLORADO MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 WILLIAMSON AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894691 | ||||||||
| FaxNumber: | 9282893855 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 WILLIAMSON AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894691 | ||||||||
| FaxNumber: | 9282893855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | FREET | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9282894691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 03-8507 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 282NC0060X | RGH0076 | AZ | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | AZ | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 176132 | 05 | AZ | MEDICAID | 020389 | 05 | AZ | MEDICAID |