Provider Demographics
NPI:1215561576
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:LOGANSPORT FAMILY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-753-1385
Mailing Address - Street 1:1101 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1528
Mailing Address - Country:US
Mailing Address - Phone:574-753-1778
Mailing Address - Fax:574-753-1359
Practice Address - Street 1:1201 MICHIGAN AVE STE 270
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1530
Practice Address - Country:US
Practice Address - Phone:574-722-4921
Practice Address - Fax:574-739-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200003920LMedicaid