Provider Demographics
NPI:1619664307
Name:MEMORIAL HEALTH GROUP LLC
Entity Type:Organization
Organization Name:MEMORIAL HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-808-5629
Mailing Address - Street 1:8131 S MEMORIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4348
Mailing Address - Country:US
Mailing Address - Phone:918-200-9944
Mailing Address - Fax:
Practice Address - Street 1:8131 S MEMORIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4348
Practice Address - Country:US
Practice Address - Phone:918-200-9944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty