Provider Demographics
| NPI: | 1235160532 |
|---|---|
| Name: | MEMORIAL HOSPITAL |
| Entity Type: | Organization |
| Organization Name: | MEMORIAL HOSPITAL |
| Other - Org Name: | MEMORIAL MEDICAL ASSOCIATES |
| 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: | 113 E WILLIAMS ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | OWOSSO |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 48867-2360 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 989-725-6528 |
| Mailing Address - Fax: | 989-723-9446 |
| Practice Address - Street 1: | 826 W KING ST |
| Practice Address - Street 2: | |
| Practice Address - City: | OWOSSO |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48867-2120 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 989-723-5211 |
| Practice Address - Fax: | 989-723-5274 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | MEMORIAL HOSPITAL |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-07-05 |
| Last Update Date: | 2022-09-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 1235160532 | Medicaid | |
| MI | 1235160532 | Medicaid | |
| MI | 0G81004 | Other | BCBSM |
| ========= | Other | TAX IDENTIFICATION NUMBER | |
| ========= | Other | TAX IDENTIFICATION NUMBER | |
| MI | 0G81004 | Other | BCBSM |
| MI | 0N56610 | Medicare ID - Type Unspecified | |
| MI | 0N56610 | Medicare ID - Type Unspecified |
