Prohealth Oconomowoc Memorial Hospital, Inc.
Organization Active NPI General Acute Care Hospital · Oconomowoc, WI
NPI 1366420531 · NPPES record last updated May 6, 2020
Key facts
- NPI
- 1366420531
- Entity type
- Organization (NPI type 2)
- Primary specialty
- General Acute Care Hospital 282N00000X
- License
- 113 (WI)
- Legal business name
- PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
- Practice address
- 791 Summit Ave
Oconomowoc, WI 53066 - Phone
- (262) 928-2510
- Fax
- (262) 928-4032
- NPI assigned
- Jan 6, 2006
- Organization subpart
- No
Authorized official
- Name
- Susan A Edwards
- Title
- Ceo
- Phone
- (262) 928-2263
Owners & managing parties with NPI records 1
-
Gary Anthony Beyer, M.D.
Other NPIs on the same Medicare enrollment 1
Corporate family (same tax ID) 2
Practitioners 3
-
Lawrence Lin, MD
-
Murrad Abdelkarim, M.D.
Affiliated clinicians 462
-
Michelle M Agnew, M.D.
-
Laith Mutasem Al-Shihabi, M.D.
-
Zuber Sherefa Ali, M.D.
-
Charles Edward Allen Jr., M.D.
-
Julie Amtmann, PA
-
Eric R Anderson, D.O.
-
Eric R Anderson, MD
-
Jon J Auger, MD
-
Stephanie Lynn Baginski, M.D.
-
Alison M Baierl, PA-C
-
Mark Glen Bakalars, M.D.
-
Katie Jane Balderas, PA-C
-
Mary Kate Baniel, PA-C
-
Brianna Barker, APNP
-
Sarah Elizabeth Barto, APRN-BC
-
Stephen R Bartos, MD
-
Arthy Baskaran, MD
-
Nabeel M. Beg, M.D.
-
Douglas J Bell, M.D.
Medicare Care Compare: Hospital
- Listed as
- Oconomowoc Memorial Hospital
- Overall star rating
- ★★★★★ 5 of 5
- Type
- Acute Care Hospitals
- Ownership
- Voluntary non-profit - Private
- Medicare certification status
- Active
- Emergency services
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Hospital certification: CCN 520062
- Legal name
- PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
- Certification status
- Active
- Provider type (POS)
- Hospital – Short-term
- Participating since
- Jul 1, 1966
- Last certification
- Nov 14, 2018
- Beds
- 156
- Ownership / control type
- Private (not for profit)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 5, 1955 in WI
- Enrollment address
- 791 Summit Ave
Oconomowoc, WI 53066-3844 - Hospital subgroups
- Acute care
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Thomas W Johnson |
W-2 Managing Employee | Aug 19, 2016 | |
| Prohealth Care Inc |
5% Or Greater Direct Ownership Interest | Feb 1, 2012 | 100% |
| Susan a Edwards |
Corporate Officer | Sep 27, 2010 | 100% |
| W-2 Managing Employee |
Sep 27, 2010 | 100% | |
| Gary Anthony Beyer |
Corporate Officer | Sep 12, 2016 | |
| Andrew S Gutierrez |
Corporate Officer |
Dec 22, 2021 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080125000448 | WI | Part a Provider - Hospital | 3779488275 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Oconomowoc, WI |
National Provider Directory
- Tax ID family
- Mem Hosp of Oconomowoc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Acute Care Hospital | 282N00000X | 113 | WI | Yes |
Addresses
Primary practice location
791 Summit Ave
Oconomowoc, WI 53066
Mailing address
791 Summit Ave
Oconomowoc, WI 53066-3844
Phone (262) 928-2510
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 11011100 | Medicaid | WI |
Other providers in Oconomowoc, WI
- Prohealth Medical Group Inc
- Prohealth Medical Group Inc
- Prohealth Medical Group Inc
- Prohealth Medical Group Inc
- Prohealth Medical Group Inc
- Prohealth Oconomowoc Memorial Hospital, Inc.
- Prohealth Oconomowoc Memorial Hospital, Inc.
- Beth Provost
- Purity Dialysis Centers, Inc
- Adam T. Quetsch
All providers in Oconomowoc, WI · General Acute Care Hospital in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 6, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.