Provider Demographics
NPI:1326183427
Name:FREEPORT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:FREEPORT MEMORIAL HOSPITAL
Other - Org Name:FHN MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-599-6000
Mailing Address - Street 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 857
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4030
Mailing Address - Country:US
Mailing Address - Phone:815-599-7958
Mailing Address - Fax:
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000778332B00000X
332BN1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL802700Medicare ID - Type Unspecified
IL140160Medicare ID - Type Unspecified
IL0524610001Medicare NSC