Healthcare Provider Details

I. General information

NPI: 1740306992
Provider Name (Legal Business Name): WAGNER COMMUNITY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 3RD ST SW
WAGNER SD
57380-9675
US

IV. Provider business mailing address

PO BOX 280
WAGNER SD
57380-0280
US

V. Phone/Fax

Practice location:
  • Phone: 605-384-3418
  • Fax: 605-384-5240
Mailing address:
  • Phone: 605-384-3418
  • Fax: 605-384-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10571
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10571
License Number StateSD
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10571
License Number StateSD

VIII. Authorized Official

Name: MRS. BERNADETTE R KOUPAL
Title or Position: BUS. OFFICE MANAGER
Credential:
Phone: 605-384-3611