Provider Demographics
NPI:1568542850
Name:PROTESTANT MEMORIAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:PROTESTANT MEMORIAL MEDICAL CENTER, INC.
Other - Org Name:MEMORIAL HOSPITAL HOME CARE
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:618-257-5700
Mailing Address - Fax:618-257-6949
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:618-257-5700
Practice Address - Fax:618-257-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1003144251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid
IL=========005Medicaid