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NPI Code Detail

MEDICARE: INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.

MEDICARE: INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
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
1261QR1300XRural Health Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1659899078
Entity Type Code : Organization
Provider Name (Legal Business Name) : INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Provider Business Mailing Address
First Line : PO BOX 300
Second Line :
City : SHELL LAKE
State : WI
Zip : 54871-0300
Country : US
Telephone Number : 715-468-7833
Fax Number :
Provider Business Practice Location Address
First Line : 113 4TH AVE
Second Line :
City : SHELL LAKE
State : WI
Zip : 54871-4457
Country : US
Telephone Number : 715-468-7833
Fax Number : 715-468-7303
Authorized Official
Title or Position : EXECUTIVE VICE PRESIDENT
Name : SHANNON JAMES JACK
Credential :
Telephone Number : 715-468-7833
Provider Enumeration Date : 09/06/2017
Last Update Date : 03/09/2020

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