Provider Demographics
NPI:1699228882
Name:MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-357-8573
Mailing Address - Street 1:110 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62326-1271
Mailing Address - Country:US
Mailing Address - Phone:217-357-2173
Mailing Address - Fax:217-357-6564
Practice Address - Street 1:110 E MARKET ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62326-1271
Practice Address - Country:US
Practice Address - Phone:309-776-3301
Practice Address - Fax:309-776-3370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-25
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid