Provider Demographics
NPI:1407932601
Name:FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:SKILLED CARE UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-842-2611
Mailing Address - Street 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-842-2611
Mailing Address - Fax:618-847-8387
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1203
Practice Address - Country:US
Practice Address - Phone:618-842-2611
Practice Address - Fax:618-847-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000679314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1049OtherBCBS
IL145552Medicare Oscar/Certification