Healthcare Provider Details

I. General information

NPI: 1245513936
Provider Name (Legal Business Name): MEMORIAL HOSPITAL OF BOSCOBEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PARKER ST
BOSCOBEL WI
53805-1642
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 608-375-4112
  • Fax:
Mailing address:
  • Phone: 952-653-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS KNOBLE
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 608-375-6307