Provider Demographics
NPI:1821186479
Name:FAIRFIELD MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:FAIRFIELD MEMORIAL HOSPITAL
Other - Org Name:WAYFAIR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-847-8260
Mailing Address - Street 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-847-8260
Mailing Address - Fax:618-847-8387
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1203
Practice Address - Country:US
Practice Address - Phone:618-847-8260
Practice Address - Fax:618-847-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040238313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1049OtherBCBS
IL1049OtherBCBS
IL=========004Medicaid