Healthcare Provider Details

I. General information

NPI: 1467583278
Provider Name (Legal Business Name): ST CLARE MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 1ST ST
OCONTO WI
54153-1117
US

IV. Provider business mailing address

103 1ST ST
OCONTO WI
54153-1117
US

V. Phone/Fax

Practice location:
  • Phone: 920-835-1144
  • Fax: 920-835-1145
Mailing address:
  • Phone: 920-835-1144
  • Fax: 920-835-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25152-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1515-23
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number212-23
License Number StateWI

VIII. Authorized Official

Name: DANIEL DEGROOT
Title or Position: CEO
Credential:
Phone: 920-846-3444