Basic Information
| Provider Information | |||||||||
| NPI: | 1801005210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/01/2008 | ||||||||
| NPIReactivationDate: | 09/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7156855512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 275 | WI | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 11019500 | 05 | WI | MEDICAID | 36585ME | 01 | MN | BCBS PROF COMPONENT | OTHER | 3901638 | 01 | WI | MEDICA PROF COMPONENT | OTHER | 0160HME | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 5025472 | 01 | WI | MEDICA | OTHER | 0160JME | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 11019526 | 05 | WI | MEDICAID | 01022385 | 01 | WI | PREFERRED ONE | OTHER | 11019521 | 05 | WI | MEDICAID |