Basic Information
| Provider Information | |||||||||
| NPI: | 1609275262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAUI MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAUI MEMORIAL MEDICAL CENTER OUTPATIENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 221 MAHALANI STREET | ||||||||
| Address2: | COTTAGE 18 | ||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082433030 | ||||||||
| FaxNumber: | 8084425652 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 MAUI LANI PARKWAY | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084425700 | ||||||||
| FaxNumber: | 8084425652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2014 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LO | ||||||||
| AuthorizedOfficialFirstName: | WESLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8084425100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HAWAII HEALTH SYSTEMS CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00005796 | 05 | HI | MEDICAID |