Provider Demographics
NPI:1437246865
Name:DECATUR MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DECATUR MEMORIAL HOSPITAL
Other - Org Name:DMH MEDICAL EQUIPMENT CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-876-4040
Mailing Address - Street 1:102 W KENWOOD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4368
Mailing Address - Country:US
Mailing Address - Phone:217-876-4040
Mailing Address - Fax:217-876-4084
Practice Address - Street 1:102 W KENWOOD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4368
Practice Address - Country:US
Practice Address - Phone:217-876-4040
Practice Address - Fax:217-876-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5870764OtherBLUE CROSS BLUE SHIELD
IL5870764OtherBLUE CROSS BLUE SHIELD
IL=========014Medicaid