Provider Demographics
NPI:1063516078
Name:BLACK RIVER MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:BLACK RIVER MEMORIAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE-JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN MHA FACHE
Authorized Official - Phone:715-284-5361
Mailing Address - Street 1:711 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615
Mailing Address - Country:US
Mailing Address - Phone:715-284-5361
Mailing Address - Fax:715-284-1390
Practice Address - Street 1:311 COUNTY ROAD A STE 1
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-8205
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:715-284-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1037251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43189700Medicaid
WI43189700Medicaid