Provider Demographics
NPI:1093198624
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:MEMORIAL HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JORRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:TREMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-729-4466
Mailing Address - Street 1:819 N SHIAWASSEE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1601
Mailing Address - Country:US
Mailing Address - Phone:989-729-4781
Mailing Address - Fax:989-729-4971
Practice Address - Street 1:819 N SHIAWASSEE ST STE 105
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1601
Practice Address - Country:US
Practice Address - Phone:989-729-4781
Practice Address - Fax:989-729-4971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-01
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000059282N00000X
3336C0002X, 3336C0003X, 3336H0001X, 3336I0012X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No282N00000XHospitalsGeneral Acute Care Hospital
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00058OtherINPATIENT/OUTPATIENT/PSYC
MI1093198624Medicaid
MI1063414233Medicaid
MI5000009OtherPHP IN/OUTPATIENT
MIM004774OtherCHAMPUS IN/OUTPATIENT
MI5000009OtherPHP IN/OUTPATIENT
MI405171252Medicaid