Provider Demographics
NPI:1962533455
Name:CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY
Entity type:Organization
Organization Name:CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN DISPENSARY
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREMBAN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:715-276-1600
Mailing Address - Street 1:14353 HWY 32 & 64
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN
Mailing Address - State:WI
Mailing Address - Zip Code:54149
Mailing Address - Country:US
Mailing Address - Phone:715-276-1600
Mailing Address - Fax:715-276-1800
Practice Address - Street 1:14353 HWY 32 & 64
Practice Address - Street 2:
Practice Address - City:MOUNTAIN
Practice Address - State:WI
Practice Address - Zip Code:54149
Practice Address - Country:US
Practice Address - Phone:715-276-1600
Practice Address - Fax:715-276-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23967-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5128904OtherNCPDP
WI395585708005OtherGREMBAN BC
WI31756500Medicaid
WIB53236Medicare UPIN