Basic Information
| Provider Information | |||||||||
| NPI: | 1811091556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY FAMILY MEMORIAL INC | ||||||||
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| OtherOrganizationName: | PHYSICIAN SERVICES - ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74W12501 LEATHERWOOD CT | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 10/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9203203470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOLY FAMILY MEMORIAL INC | ||||||||
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| NPICertificationDate: | 10/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100161580 | 05 | WI | MEDICAID | CH0881 | 01 | WI | RAILROAD MEDICARE | OTHER | 32795700 | 05 | WI | MEDICAID |