Provider Demographics
NPI:1871796052
Name:MEMORIAL HOSPITAL OF BOSCOBEL
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF BOSCOBEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-375-6203
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-6217
Mailing Address - Fax:608-375-5463
Practice Address - Street 1:208 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1648
Practice Address - Country:US
Practice Address - Phone:608-375-2424
Practice Address - Fax:608-375-6285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF BOSCOBEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-06
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21315200Medicaid
WI43061800Medicaid
WI2706440002Medicare PIN
WI52-8523Medicare PIN
WI2706440004Medicare PIN
WI000024160Medicare PIN
WI000000486Medicare PIN
WI2706440003Medicare PIN