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General NPI Number Information
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NPI Number | 1962533455
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Entity Type | Organization
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Legal Business Name | CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 12/23/2021
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Provider Practice Location Address
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Address Line | 14353 HWY 32 & 64
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City | MOUNTAIN
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State | WI
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Zip | 54149
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Country | US
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Telephone | 715-276-1600
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Fax | 715-276-1800
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Provider Business Mailing Address
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Address Line | 14353 HWY 32 & 64
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City | MOUNTAIN
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State | WI
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Zip | 54149
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Country | US
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Telephone | 715-276-1600
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Fax | 715-276-1800
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Authorized Official
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Title or Position | PHYSICIAN DISPENSARY
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Name | DOUGLAS C GREMBAN II
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Credential | M.D.
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Telephone | 715-276-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 23967-020
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License Number State | WI
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