Provider Demographics
NPI:1568715126
Name:MEMORIAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MEMORIAL PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, MPS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-3342
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:515 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1401
Practice Address - Country:US
Practice Address - Phone:217-732-9681
Practice Address - Fax:217-735-6527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143895OtherRHC MEDICARE PTAN