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General NPI Number Information
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NPI Number | 1366420531
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Entity Type | Organization
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Legal Business Name | PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
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Dates
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Enumeration Date | 01/06/2006
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Last Update Date | 05/06/2020
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Provider Practice Location Address
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Address Line | 791 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066
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Country | US
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Telephone | 262-928-2510
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Fax | 262-928-4032
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Provider Business Mailing Address
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Address Line | 791 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3844
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Country | US
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Telephone | 262-928-2510
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Fax | 262-928-4032
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Authorized Official
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Title or Position | CEO
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Name | SUSAN A EDWARDS
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Credential |
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Telephone | 262-928-2263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 113
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License Number State | WI
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