Provider Demographics
NPI:1649589268
Name:MEMORIAL HOSPITAL OF CARBONDALE
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF CARBONDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, PRE-ANESTHESIA
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SURBURG
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-BC
Authorized Official - Phone:618-549-0721
Mailing Address - Street 1:405 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:618-529-0431
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0431
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008246282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital