Provider Demographics
NPI:1427376060
Name:MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEM
Other - Org Name:MEMORIAL PHYSICIAN NETWORK- PEDIATIRC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:YANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-365-9951
Mailing Address - Street 1:1725 E BOULDER ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5768
Mailing Address - Country:US
Mailing Address - Phone:719-365-9951
Mailing Address - Fax:
Practice Address - Street 1:1725 E BOULDER ST
Practice Address - Street 2:SUITE 104
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5768
Practice Address - Country:US
Practice Address - Phone:719-365-9951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-06
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty