Provider Demographics
NPI:1922115914
Name:MEMORIAL HEALTH SYSTEMS INC
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEMS INC
Other - Org Name:ADVENTHEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-231-3906
Mailing Address - Street 1:770 W GRANADA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5179
Mailing Address - Country:US
Mailing Address - Phone:863-231-4252
Mailing Address - Fax:386-676-2560
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 205
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-3530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40181JOtherMEDICARE ID UNSPECIFIED
FL40181JMedicare PIN
FL40181JOtherMEDICARE ID UNSPECIFIED