MEDICARE: MEMORIAL HOSPITAL 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
1	332900000X	Non-Pharmacy Dispensing Site	641-23	WI
2	261QR1300X	Rural Health Clinic/Center		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	:	1801270962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL HOSPITAL INC

Provider Business Mailing Address
First Line	:	216 SUNSET PL
Second Line	:
City	:	NEILLSVILLE
State	:	WI
Zip	:	54456-1706
Country	:	US
Telephone Number	:	715-743-3101
Fax Number	:	715-743-8022

Provider Business Practice Location Address
First Line	:	502 E ELM DR
Second Line	:
City	:	LOYAL
State	:	WI
Zip	:	54446-9604
Country	:	US
Telephone Number	:	715-255-8551
Fax Number	:	715-743-8022

Authorized Official
Title or Position	:	CEO
Name	:	RYAN T NEVILLE
Credential	:
Telephone Number	:	715-743-8449

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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