Provider Demographics
NPI:1609040179
Name:MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL, INC.
Other - Org Name:FAMILY MEDICAL CARE OF CLAY COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-598-5104
Mailing Address - Street 1:509 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6195
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:94 MARIE LANGDON DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6353
Practice Address - Country:US
Practice Address - Phone:606-598-5104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31001134Medicaid
KY65934523Medicaid
CC2941OtherRR MEDICARE
CC2941OtherRR MEDICARE