Healthcare Provider Details

I. General information

NPI: 1497942205
Provider Name (Legal Business Name): PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 SUMMIT AVE STE 1106
OCONOMOWOC WI
53066-3844
US

IV. Provider business mailing address

791 SUMMIT AVE
OCONOMOWOC WI
53066-3844
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-0284
  • Fax: 262-569-0539
Mailing address:
  • Phone: 262-569-0284
  • Fax: 262-569-0539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8772
License Number StateWI

VIII. Authorized Official

Name: THOMAS JOHNSON
Title or Position: REIMBURSEMENT MANAGER
Credential:
Phone: 262-928-4704