NPIMap

Organization Active NPI

Prohealth Oconomowoc Memorial Hospital, Inc.

Doing business as ProHealth Pharmacy - Oconomowoc

  • Community/Retail Pharmacy
  • Oconomowoc, WI
National Provider Identifier
1497942205
Registry record updated Dec 14, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
8772 Issued in WI
Legal business name
PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
Doing business as
ProHealth Pharmacy - Oconomowoc
Practice address
791 Summit Ave Ste 1106
Oconomowoc, WI 53066-3844
Phone
(262) 569-0284
Fax
(262) 569-0539
NPI assigned
Sep 26, 2007
Last updated
Dec 14, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 14, 2022

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

Authorized official

Name
Thomas Johnson
Title
Reimbursement Manager
Phone
(262) 928-4704

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 8772 WI Primary

Addresses

Primary practice location

791 Summit Ave Ste 1106
Oconomowoc, WI 53066-3844

Mailing address

791 Summit Ave
Oconomowoc, WI 53066-3844
Phone (262) 569-0284

Other names 1

  • ProHealth Pharmacy - Oconomowoc Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080125000448 WI Part A Provider - Hospital 3779488275 1 other NPI on this enrollment
Practice locations: Oconomowoc, WI
O20230822002431 WI Part B Supplier - Pharmacy 3779488275 Practice locations: Oconomowoc, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497942205. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Jun 5, 1955 in WI
Enrollment address
791 Summit Ave
Oconomowoc, WI 53066-3844
Main/Primary Hospital Location
Hospital subgroups
Acute care

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Oconomowoc Memorial HospitalCCN 520062 · All quality measures
Overall star rating
5 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Prohealth Oconomowoc Memorial Hospital Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1185 Corporate Center Dr
Ste 135
Oconomowoc, WI 53066
Phone 26252188002

1185 Corporate Center Dr
Ste 215
Oconomowoc, WI 53066
Phone (262) 928-8440

1185 Corporate Center Dr
Ste 240
Oconomowoc, WI 53066
Phone (262) 928-6236

791 Summit Ave
Ste 1106
Oconomowoc, WI 53066
Phone (262) 569-0284

791 Summit Ave
Summit, WI 53066
Phone (262) 569-0251

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Thomas W Johnson Individual W-2 Managing Employee Aug 19, 2016
Prohealth Care Inc Organization, Waukesha, WI Non-profit 5% Or Greater Direct Ownership Interest Feb 1, 2012 100%
Susan a Edwards Individual Corporate Officer Sep 27, 2010 100%
W-2 Managing EmployeeCeo Sep 27, 2010 100%
Gary Anthony Beyer Individual Corporate Officer Sep 12, 2016
Andrew S Gutierrez Individual Corporate OfficerCfo Dec 22, 2021 100%

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 3

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

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 462

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

View all 462

NPI Registry JSON

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

{
    "created_epoch": "1190764800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670976000000",
    "number": "1497942205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "791 SUMMIT AVE",
            "city": "OCONOMOWOC",
            "state": "WI",
            "postal_code": "530663844",
            "telephone_number": "262-569-0284",
            "fax_number": "262-569-0539"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "791 SUMMIT AVE STE 1106",
            "city": "OCONOMOWOC",
            "state": "WI",
            "postal_code": "530663844",
            "telephone_number": "262-569-0284",
            "fax_number": "262-569-0539"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-26",
        "last_updated": "2022-12-14",
        "certification_date": "2022-12-14",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "REIMBURSEMENT MANAGER",
        "authorized_official_telephone_number": "262-928-4704"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8772",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ProHealth Pharmacy - Oconomowoc",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "ProHealth Pharmacy - Oconomowoc",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Oconomowoc, WI

Sources for this page

Verify at the official NPI Registry.