Provider Demographics
NPI:1326000100
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:REGISTERED DIETICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-3340
Mailing Address - Street 1:701 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-757-7491
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-757-7491
Practice Address - Fax:217-757-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200743Medicare ID - Type Unspecified