Provider Demographics
NPI:1568668754
Name:MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEM
Other - Org Name:MEMORIAL HOSPITAL PHYS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCIALDONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-365-2068
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80901-0460
Mailing Address - Country:US
Mailing Address - Phone:719-365-5242
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0244207Q00000X, 207R00000X, 207V00000X, 208000000X, 208600000X, 208M00000X
CO282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC5004OtherBLUE CROSS
CO04762084Medicaid
COC5004OtherBLUE CROSS
CO=========OtherALL OTHER PAYORS