Healthcare Provider Details

I. General information

NPI: 1346371358
Provider Name (Legal Business Name): ST CLARE MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S. ROSERA STREET
LENA WI
54139
US

IV. Provider business mailing address

855 S MAIN ST
OCONTO FALLS WI
54154-1241
US

V. Phone/Fax

Practice location:
  • Phone: 920-829-6400
  • Fax: 920-829-6403
Mailing address:
  • Phone: 920-846-3444
  • Fax: 920-846-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1428-023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38208-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA ALLEN
Title or Position: CFO
Credential:
Phone: 920-884-5660