Provider Demographics
NPI:1588673628
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:CENTEGRA HOSPITAL WOODSTOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CIO & CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-788-5831
Mailing Address - Street 1:527 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3756
Mailing Address - Country:US
Mailing Address - Phone:815-338-2500
Mailing Address - Fax:815-334-3948
Practice Address - Street 1:527 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3756
Practice Address - Country:US
Practice Address - Phone:815-338-2500
Practice Address - Fax:815-334-3948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-07
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001503314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1159OtherBLUE CROSS
IL=========OtherALL OTHERS
IL=========OtherALL OTHERS