Provider Demographics
NPI:1497807689
Name:WABASH MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:WABASH MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS-TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-425-9642
Mailing Address - Street 1:1501 N WATER ST
Mailing Address - Street 2:PO BOX 1340
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4441
Mailing Address - Country:US
Mailing Address - Phone:217-425-9642
Mailing Address - Fax:217-542-0134
Practice Address - Street 1:1501 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4441
Practice Address - Country:US
Practice Address - Phone:217-425-9642
Practice Address - Fax:217-542-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117078261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center