Provider Demographics
NPI:1588614002
Name:MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-357-8573
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-0160
Mailing Address - Country:US
Mailing Address - Phone:217-357-2173
Mailing Address - Fax:217-357-3610
Practice Address - Street 1:1450 N COUNTY RD 2050
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-0160
Practice Address - Country:US
Practice Address - Phone:217-357-2173
Practice Address - Fax:217-357-3610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA=========Medicaid
IA=========Medicaid
IAI16700Medicare PIN
IL803070Medicare ID - Type Unspecified