Provider Demographics
NPI:1790788578
Name:MASSAC MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MASSAC MEMORIAL HOSPITAL
Other - Org Name:MASSAC MEMORIAL HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-524-2176
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:28 CHICK ST
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-0850
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-524-4131
Practice Address - Street 1:28 CHICK ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-2176
Practice Address - Fax:618-524-4131
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASSAC COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001420282NC0060X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL13019Medicaid
TN0140042Medicaid
037520699OtherENERGY EMPLOYEES OCCUP IL
IL6415006OtherBLUE SHIELD ILLINOIS
KY01330034Medicaid
111575OtherHEALTHLINK
IL317OtherBLUE CROSS ILLINOIS
TN3582OtherBLUE CROSS
HEALTH ALLIANCEOther000795
111575OtherHEALTHLINK
IL=========401Medicaid
910950Medicare ID - Type UnspecifiedMEDICARE B ANESTHESIA
KY01330034Medicaid
HEALTH ALLIANCEOther000795
TN0140042Medicaid