Basic Information
| Provider Information | |||||||||
| NPI: | 1720029804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC DBA WAUSHARA FAMILY PHYSICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | WILD ROSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549840243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206225560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 GROVE AVENUE | ||||||||
| Address2: | |||||||||
| City: | WILD ROSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549840243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206225560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | CAVES | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9206225576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32829100 | 05 | WI | MEDICAID |