Provider Demographics
NPI:1376688978
Name:MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND INC
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND INC
Other - Org Name:MEMORIAL HOSPITAL PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-723-6414
Mailing Address - Street 1:600 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3765
Mailing Address - Country:US
Mailing Address - Phone:301-723-1443
Mailing Address - Fax:301-723-1480
Practice Address - Street 1:600 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3765
Practice Address - Country:US
Practice Address - Phone:301-723-1443
Practice Address - Fax:301-723-1480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X
208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCE458OtherBLUE CHOICE
MDKP01MEOtherCAREFIRST BC BS
MDCH1651OtherTRAVELERS MEDICARE
MDCH1651OtherTRAVELERS MEDICARE