Provider Demographics
NPI:1275640997
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:VP
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:383-231-3906
Mailing Address - Street 1:PO BOX 730729
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-0729
Mailing Address - Country:US
Mailing Address - Phone:386-671-4500
Mailing Address - Fax:386-672-9904
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 2811
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5999
Practice Address - Country:US
Practice Address - Phone:386-671-4519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40181Medicare ID - Type UnspecifiedMEDICARE GROUP ID