NPIMap

Organization Active NPI

Memorial Hospital of Boscobel

  • Medicare Defined Swing Bed Hospital Unit
  • Boscobel, WI
National Provider Identifier
1497712624
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
Legal business name
MEMORIAL HOSPITAL OF BOSCOBEL
Doing business as
memorial hospital of boscobel
Practice address
205 Parker St
Boscobel, WI 53805-1642
Phone
(608) 375-4112
NPI assigned
May 1, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Gary Bezucha
Title
Administrator
Phone
(608) 375-4112

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X NU Primary

Addresses

Primary practice location

205 Parker St
Boscobel, WI 53805-1642

Mailing address

205 Parker St
Boscobel, WI 53805-1642
Phone (608) 375-4112

Other names 1

  • memorial hospital of boscobel Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040115000725 WI Part B Supplier - Clinic/Group Practice 8325957673 Receives reassigned benefits from 316 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Viroqua, WI; Whitehall, WI; Prairie Du Chien, WI; Onalaska, WI; Muscoda, WI; Milwaukee, WI; Mequon, WI; La Crosse, WI…
O20220816002495 WI Part A Provider - Critical Access Hospital 8325957673 Practice locations: Boscobel, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497712624. Details of each certification follow.

Hospital certification: CCN 52Z344

Legal name
MEMORIAL HOSPITAL OF BOSCOBEL
Doing business as
GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS
Organization structure
CorporationNon-profit
Incorporated
May 1, 1952 in WI
Enrollment address
205 Parker St
Boscobel, WI 53805-1642
Main/Primary Hospital Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

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

Locations

13500 Watertown Plank Rd
Ste 206
Elm Grove, WI 53122

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gary Boughton Individual Corporate Director Feb 1, 2022
Gerald Berge Individual Corporate DirectorBoard Member Jan 25, 2005
Jennifer Boigenzahn Individual Corporate DirectorChief Financial Officer Sep 16, 2020
Andrew W Nahas Individual Corporate Director Dec 17, 2019
Cynde Larsen Individual Corporate DirectorBoard Member Dec 1, 2016
Krister Mattson Individual Corporate DirectorBoard Member Aug 25, 2025
Alan Eber Individual Corporate Director Feb 1, 2022
Bellin Gundersen Health System Inc Organization, La Crosse, WI Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Nov 30, 2022 100%
Operational/Managerial Control Nov 30, 2022
Emily McCormick Individual Corporate DirectorBoard Member Jan 1, 2024
Gundersen Lutheran Health System Inc Organization, La Crosse, WI Corporation, Non-profit 5% Or Greater Direct Ownership Interest Oct 1, 2023 100%
Operational/Managerial Control Oct 1, 2013 100%
Kelsey Cordova Individual Corporate DirectorBoard Member Jan 1, 2026
Tim Wilson Individual Corporate DirectorBoard Member Jan 1, 2025
Theresa Braudt Individual Corporate Director Dec 1, 2019
W-2 Managing Employee Dec 1, 2019

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 49

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 49

Practitioners & affiliated clinicians

Practitioners 318

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 318

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1146441600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1497712624",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 PARKER ST",
            "city": "BOSCOBEL",
            "state": "WI",
            "postal_code": "538051642",
            "telephone_number": "608-375-4112"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 PARKER ST",
            "city": "BOSCOBEL",
            "state": "WI",
            "postal_code": "538051642",
            "telephone_number": "608-375-4112"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL OF BOSCOBEL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BEZUCHA",
        "authorized_official_first_name": "GARY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "608-375-4112"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "memorial hospital of boscobel",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boscobel, WI

Sources for this page

Verify at the official NPI Registry.