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General NPI Number Information
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NPI Number | 1093096224
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Entity Type | Organization
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Legal Business Name | COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
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Dates
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Enumeration Date | 09/01/2011
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Last Update Date | 01/13/2012
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Provider Practice Location Address
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Address Line | 1726 SHAWANO AVE
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City | GREEN BAY
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State | WI
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Zip | 54303-3216
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Country | US
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Telephone | 920-360-3787
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Fax | 888-848-0225
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Provider Business Mailing Address
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Address Line | 25630 NETWORK PL
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City | CHICAGO
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State | IL
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Zip | 60673-1256
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Country | US
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Telephone | 920-360-3787
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Fax | 888-848-0225
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Authorized Official
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Title or Position | CEO
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Name | DANIEL DEGROOT
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Credential |
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Telephone | 920-846-3444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 39597-20
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License Number State | WI
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