Provider Demographics
NPI:1598094153
Name:DECATUR MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DECATUR MEMORIAL HOSPITAL
Other - Org Name:DMH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:RIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-876-2857
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:GSBLL
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-2857
Practice Address - Fax:217-876-2874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========401Medicaid