Provider Demographics
NPI:1558432237
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:MEMORIAL HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISDELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-723-5211
Mailing Address - Street 1:826 W KING ST
Mailing Address - Street 2:PO BOX 456
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2120
Mailing Address - Country:US
Mailing Address - Phone:989-729-6353
Mailing Address - Fax:
Practice Address - Street 1:802 W KING ST
Practice Address - Street 2:SUITE N
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-729-4041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041531208600000X
MI5601003225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX IDENTIFICATION NUMBER