Provider Demographics
NPI:1285926501
Name:LADD MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:LADD MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:FORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-294-5622
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0218
Mailing Address - Country:US
Mailing Address - Phone:715-294-4050
Mailing Address - Fax:715-294-5690
Practice Address - Street 1:2600 65TH AVENUE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-0218
Practice Address - Country:US
Practice Address - Phone:715-294-4050
Practice Address - Fax:715-294-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9071-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6785710001Medicare NSC