Provider Demographics
NPI:1477633766
Name:PROTESTANT MEMORIAL MEDICAL CENTER,INC
Entity Type:Organization
Organization Name:PROTESTANT MEMORIAL MEDICAL CENTER,INC
Other - Org Name:MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-5648
Mailing Address - Street 1:4500 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-233-7750
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-233-7750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001461282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008219585OtherBLUE SHIELD
=========001OtherTRICARE
IL=========401Medicaid
IL801000Medicare ID - Type Unspecified