Basic Information
| Provider Information | |||||||||
| NPI: | 1568438125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANHEAD MEDICAL CENTER SHELL LAKE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 4TH AVENUE | ||||||||
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| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154687833 | ||||||||
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| Address1: | 113 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154687833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACK | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7154687833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1047 | WI | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.