Provider Demographics
NPI:1437100831
Name:MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:BOWEN FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-357-8566
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:BOWEN
Mailing Address - State:IL
Mailing Address - Zip Code:62316-0105
Mailing Address - Country:US
Mailing Address - Phone:217-842-5211
Mailing Address - Fax:217-842-5202
Practice Address - Street 1:209 E 5TH STREET
Practice Address - Street 2:
Practice Address - City:BOWEN
Practice Address - State:IL
Practice Address - Zip Code:62316
Practice Address - Country:US
Practice Address - Phone:217-842-5211
Practice Address - Fax:217-842-5202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001529261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3420307OtherBLUE SHIELD
IL=========006Medicaid
IL3420307OtherBLUE SHIELD