Basic Information
| Provider Information | |||||||||
| NPI: | 1366878449 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERY REGIONAL MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMERY HOSPITAL & CLINIC -CLEAR LAKE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 357 THIRD AVE | ||||||||
| Address2: | |||||||||
| City: | CLEAR LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540050177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | 7152683102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | RUDQUIST | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7152688000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 52DO394232 | 01 | WI | CLIA | OTHER | 528562 | 01 | WI | RURAL HEALTH CLINIC | OTHER |