Basic Information
| Provider Information | |||||||||
| NPI: | 1801394549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LADD MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OSCEOLA MEDICAL CENTER OSCEOLA CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540200218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 65TH AVE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540204370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152945758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2018 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | FORGE | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7152945622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1021 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.