MEDICARE: ST. MARY'S HOSPITAL OF SUPERIOR

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	261QC0050X	Critical Access Hospital Clinic/Center	5516-800	WI

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

General Provider Information

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

Provider Business Mailing Address
First Line	:	3500 TOWER AVE
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-5335
Country	:	US
Telephone Number	:	715-817-7100
Fax Number	:	715-395-5433

Provider Business Practice Location Address
First Line	:	3500 TOWER AVE
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-5335
Country	:	US
Telephone Number	:	715-817-7100
Fax Number	:	715-395-5433

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	KEVIN BOREN
Credential	:
Telephone Number	:	218-786-1009

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	02/28/2024

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