Provider Demographics
NPI:1447228788
Name:FREEPORT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:FREEPORT MEMORIAL HOSPITAL
Other - Org Name:FHN-MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-6000
Mailing Address - Street 1:1045 W STEPHENSON ST
Mailing Address - Street 2:PO BOX 857
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4864
Mailing Address - Country:US
Mailing Address - Phone:815-599-6000
Mailing Address - Fax:
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL059-003025282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000778OtherDEPT OF PUBLIC HLTH LIC
IL187OtherBLUE CROSS
IL=========401Medicaid
IL=========001Medicaid
IL802700Medicare PIN
IL140160Medicare PIN