Provider Demographics
NPI:1326564246
Name:THE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:THE MEMORIAL HOSPITAL
Other - Org Name:COMMUNITY CLINICS AT MEMORIAL REGIONAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:ANNALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-824-9411
Mailing Address - Street 1:750 HOSPITAL LOOP
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-8750
Mailing Address - Country:US
Mailing Address - Phone:970-824-9411
Mailing Address - Fax:970-826-3119
Practice Address - Street 1:750 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-8750
Practice Address - Country:US
Practice Address - Phone:970-824-9411
Practice Address - Fax:970-826-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
COPDO.16800001523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000156463Medicaid
2171012OtherPK