Provider Demographics
NPI:1629469002
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:RANDOLPH HOSPITAL DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIESNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-826-4581
Mailing Address - Street 1:1900 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1116
Mailing Address - Country:US
Mailing Address - Phone:618-826-4581
Mailing Address - Fax:
Practice Address - Street 1:2319 OLD PLANK ROAD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1116
Practice Address - Country:US
Practice Address - Phone:618-826-2388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051292207Q00000X
IL036-052369207Q00000X
IL036-130378207Q00000X
IL036-087561207Q00000X
IL036-127160208600000X
IL036-046019208600000X
261QR1300X
IL0001495282NC0060X
IL085-003568363A00000X
IL085-003575363A00000X
IL209-009681363L00000X
IL041-149926367500000X
IL209-009387367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
812110Medicare PIN