Provider Demographics
NPI:1235161209
Name:DOUGLAS COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DOUGLAS COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-724-2151
Mailing Address - Street 1:1311 BRADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:ARMOUR
Mailing Address - State:SD
Mailing Address - Zip Code:57313-2136
Mailing Address - Country:US
Mailing Address - Phone:605-724-2970
Mailing Address - Fax:605-724-2310
Practice Address - Street 1:1311 BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:ARMOUR
Practice Address - State:SD
Practice Address - Zip Code:57313-2136
Practice Address - Country:US
Practice Address - Phone:605-724-2970
Practice Address - Fax:605-724-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10018483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8502460Medicaid
SD9167440OtherMEDICAID DME
SD8502460Medicaid