MEDICARE: COMMUNITY MEMORIAL HOSPITAL, INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1851477913	OTHER		CMH NPI

General Provider Information

NPI Number	:	1437470572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY MEMORIAL HOSPITAL, INCORPORATED

Provider Business Mailing Address
First Line	:	855 S MAIN ST
Second Line	:
City	:	OCONTO FALLS
State	:	WI
Zip	:	54154-1241
Country	:	US
Telephone Number	:	920-846-3444
Fax Number	:	920-846-0250

Provider Business Practice Location Address
First Line	:	103 1ST ST
Second Line	:
City	:	OCONTO
State	:	WI
Zip	:	54153-1117
Country	:	US
Telephone Number	:	920-835-1144
Fax Number	:	920-835-1145

Authorized Official
Title or Position	:	CEO
Name	:	DANIEL DEGROOT
Credential	:
Telephone Number	:	920-846-3444

Provider Enumeration Date	:	06/11/2010
Last Update Date	:	09/28/2011

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