Provider Demographics
NPI:1730139031
Name:MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-357-8566
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-0160
Mailing Address - Country:US
Mailing Address - Phone:217-357-8500
Mailing Address - Fax:217-357-6564
Practice Address - Street 1:1454 N COUNTY ROAD 2050
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-3551
Practice Address - Country:US
Practice Address - Phone:217-357-8562
Practice Address - Fax:217-357-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005611282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0901017Medicaid
ILL012131OtherTRICARE
MO010495307Medicaid
IL3415003OtherBLUE SHIELD
IL0199OtherBLUE CROSS
IL113150OtherHEALTHLINK
IL=========003Medicaid
IL=========401Medicaid
IL=========OtherTRICARE
ILL012131OtherTRICARE
IL14Z305Medicare ID - Type Unspecified
IL803070Medicare ID - Type Unspecified
IL208476Medicare ID - Type Unspecified
IL211948Medicare ID - Type Unspecified
IL803060Medicare ID - Type Unspecified
IL141305Medicare ID - Type Unspecified
MO010495307Medicaid
IA0901017Medicaid
IL792890Medicare ID - Type Unspecified