Provider Demographics
NPI:1609510502
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHYSICIAN BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-588-2626
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:217-588-2624
Mailing Address - Fax:217-757-7550
Practice Address - Street 1:320 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5185
Practice Address - Country:US
Practice Address - Phone:217-788-3948
Practice Address - Fax:217-527-3209
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1033171343OtherMMC NPI