Provider Demographics
NPI:1184667735
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:HOSPICE OF MEMORIAL HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:LITTELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-334-6661
Mailing Address - Street 1:715 SOUTH TAFT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3200
Mailing Address - Country:US
Mailing Address - Phone:419-332-7321
Mailing Address - Fax:419-332-5875
Practice Address - Street 1:430 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-2142
Practice Address - Country:US
Practice Address - Phone:419-547-6419
Practice Address - Fax:419-547-9459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-13
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0054HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820204Medicaid
OH361513Medicare Oscar/Certification