NPIMap

Organization Active NPI

Community Memorial Hospital, Incorporated

Doing business as d/b/a Breast Surgery Experts of Northeast Wisconsin LLC

  • Surgery Physician
  • Green Bay, WI
National Provider Identifier
1093096224
Registry record updated Jan 13, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
39597-20 Issued in WI
Legal business name
COMMUNITY MEMORIAL HOSPITAL, INCORPORATED
Doing business as
d/b/a Breast Surgery Experts of Northeast Wisconsin LLC
Practice address
1726 Shawano Ave
Green Bay, WI 54303-3216
Phone
(920) 360-3787
Fax
(888) 848-0225
NPI assigned
Sep 1, 2011
Last updated
Jan 13, 2012By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY MEMORIAL HOSPITAL, INCORPORATEDAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 13, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Daniel Degroot
Title
Ceo
Phone
(920) 846-3444

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X 39597-20 WI Primary

Addresses

Primary practice location

1726 Shawano Ave
Green Bay, WI 54303-3216

Mailing address

25630 Network PL
Chicago, IL 60673-1256
Phone (920) 360-3787

Other identifiers 3

IdentifierTypeStateIssuer
1851477913OtherWICMH NPI
WI2552OtherWIMEDICARE PTAN
1750302089OtherWIPROVIDER

Other names 1

  • d/b/a Breast Surgery Experts of Northeast Wisconsin LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041023000037 WI Part B Supplier - Clinic/Group Practice 0446211395 Receives reassigned benefits from 239 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Green Bay, WI; Suring, WI; Sturgeon Bay, WI; Oconto Falls, WI; Mountain, WI; Marinette, WI; Lena, WI; Gillett, WI

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
CMH Mountain Primary Care Clinic

Locations

855 S Main St
Oconto Falls, WI 54154
Phone (920) 846-3444

Interoperability endpoints

  • FHIR API: https://eprescribe.sanfordhealth.org/FHIR/api/FHIR/R4/

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1314835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1326412800000",
    "number": "1093096224",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25630 NETWORK PL",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606731256",
            "telephone_number": "920-360-3787",
            "fax_number": "888-848-0225"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1726 SHAWANO AVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543033216",
            "telephone_number": "920-360-3787",
            "fax_number": "888-848-0225"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY MEMORIAL HOSPITAL, INCORPORATED",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY MEMORIAL HOSPITAL, INCORPORATED",
        "enumeration_date": "2011-09-01",
        "last_updated": "2012-01-13",
        "status": "A",
        "authorized_official_last_name": "DEGROOT",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "920-846-3444"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WI",
            "license": "39597-20",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CMH NPI",
            "identifier": "1851477913",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "WI2552",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PROVIDER",
            "identifier": "1750302089",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "d/b/a Breast Surgery Experts of Northeast Wisconsin LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Green Bay, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 13, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.