Provider Demographics
NPI:1215124029
Name:MEMORIAL HOSPITAL OF BOSCOBEL
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF BOSCOBEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-375-6285
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-6217
Mailing Address - Fax:608-375-5463
Practice Address - Street 1:220 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809-1030
Practice Address - Country:US
Practice Address - Phone:608-822-3737
Practice Address - Fax:608-822-3738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF BOSCOBEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-26
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2706440003Medicare NSC