Healthcare Provider Details

I. General information

NPI: 1215124029
Provider Name (Legal Business Name): MEMORIAL HOSPITAL OF BOSCOBEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LINCOLN AVE
FENNIMORE WI
53809-1030
US

IV. Provider business mailing address

205 PARKER ST
BOSCOBEL WI
53805-1642
US

V. Phone/Fax

Practice location:
  • Phone: 608-822-3737
  • Fax: 608-822-3738
Mailing address:
  • Phone: 608-375-6217
  • Fax: 608-375-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateWI

VIII. Authorized Official

Name: MARK RANDALL
Title or Position: PRESIDENT & CHAIRMAN OF THE BOARD
Credential:
Phone: 608-375-6285