MEDICARE: ST CLARE MEMORIAL HOSPITAL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner
2	207Q00000X	Family Medicine Physician	38713-020	WI
3	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1851477913	OTHER		CMH NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1639340995	OTHER	WI	BOUCHER NPI
4	1710966288	OTHER	WI	MALTINSKI NPI

General Provider Information

NPI Number	:	1134250905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CLARE MEMORIAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	855 S MAIN ST
Second Line	:
City	:	OCONTO FALLS
State	:	WI
Zip	:	54154-1241
Country	:	US
Telephone Number	:	920-846-3444
Fax Number	:	920-846-0250

Provider Business Practice Location Address
First Line	:	340 N GREEN BAY AVE
Second Line	:
City	:	GILLETT
State	:	WI
Zip	:	54124-9325
Country	:	US
Telephone Number	:	920-855-2823
Fax Number	:	920-855-6343

Authorized Official
Title or Position	:	MARKET DIRECTOR-FINANCE OPERATIONS-
Name	:	TRAVIS PITZEN
Credential	:
Telephone Number	:	920-431-3047

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	02/12/2026

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Directions to “ST CLARE MEMORIAL HOSPITAL, INC ” Practice Location

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