Healthcare Provider Details

I. General information

NPI: 1841349271
Provider Name (Legal Business Name): BURNETT MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

IV. Provider business mailing address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

V. Phone/Fax

Practice location:
  • Phone: 715-463-7261
  • Fax: 715-463-2423
Mailing address:
  • Phone: 715-463-7261
  • Fax: 715-463-2423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number6346-042
License Number StateWI

VIII. Authorized Official

Name: MR. CHARLES J. FAUGHT
Title or Position: CFO
Credential:
Phone: 715-463-7281