Basic Information
| Provider Information | |||||||||
| NPI: | 1700195542 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LADD MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OSCEOLA MEDICAL CENTER SCANDIA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540200218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152945758 | ||||||||
| Practice Location | |||||||||
| Address1: | 21150 OZARK AVE N | ||||||||
| Address2: | |||||||||
| City: | SCANDIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550739447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152945758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORGE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7152945622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LADD MEMORIAL HOSPITAL DBA OSCEOLA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.