Provider Demographics
NPI:1033146279
Name:FREEPORT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:FREEPORT MEMORIAL HOSPITAL
Other - Org Name:FHN HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SIMON
Authorized Official - Last Name:GRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-6402
Mailing Address - Street 1:773 W LINCOLN ST STE 403
Mailing Address - Street 2:PO BOX 857
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4980
Mailing Address - Country:US
Mailing Address - Phone:851-599-7240
Mailing Address - Fax:
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid
IL=========006Medicaid