Healthcare Provider Details

I. General information

NPI: 1588691588
Provider Name (Legal Business Name): ST. MARY'S HOSPITAL OF SUPERIOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 TOWER AVE
SUPERIOR WI
54880-5335
US

IV. Provider business mailing address

3500 TOWER AVE
SUPERIOR WI
54880-5335
US

V. Phone/Fax

Practice location:
  • Phone: 715-817-7100
  • Fax: 715-395-5433
Mailing address:
  • Phone: 715-817-7100
  • Fax: 715-395-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License Number5516-800
License Number StateWI

VIII. Authorized Official

Name: KEVIN BOREN
Title or Position: VP OF FINANCE
Credential:
Phone: 218-786-1009