Organization
COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Active
Parent organization
COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Other names
d/b/a Breast Surgery Experts of Northeast Wisconsin LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Authorized official
DANIEL DEGROOT (CEO)
(920) 846-3444
Entity
Organization
Contact information
Practice address
1726 SHAWANO AVE, GREEN BAY, WI 54303-3216
(920) 360-3787
(888) 848-0225
Mailing address
25630 NETWORK PL, CHICAGO, IL 60673-1256
(920) 360-3787
(888) 848-0225
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
39597-20
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1750302089
PROVIDER
WI
01
—
1851477913
CMH NPI
WI
01
—
WI2552
MEDICARE PTAN
WI
Enumeration date
09/01/2011
Last updated
01/13/2012
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