Provider Demographics
NPI:1225008543
Name:SALEM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SALEM MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-729-6626
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:35629 HIGHWAY 72
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-0774
Mailing Address - Country:US
Mailing Address - Phone:573-729-6626
Mailing Address - Fax:573-729-6502
Practice Address - Street 1:35629 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-7217
Practice Address - Country:US
Practice Address - Phone:573-729-6626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO25234261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010570307Medicaid
262315Medicare Oscar/Certification
MO010570307Medicaid