Provider Demographics
NPI:1790209518
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:618-826-4813
Practice Address - Street 1:1900 STATE ST
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:618-826-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid