Provider Demographics
NPI:1295772093
Name:MEMORIAL HOSPITAL OF SOUTH BEND
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF SOUTH BEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
Mailing Address - Street 1:615 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN005053207P00000X, 225X00000X, 261QC1500X, 332B00000X, 3416A0800X
273R00000X, 341600000X
IN06-005053273Y00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No273R00000XHospital UnitsPsychiatric UnitGroup - Multi-Specialty
No273Y00000XHospital UnitsRehabilitation UnitGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No341600000XTransportation ServicesAmbulanceGroup - Multi-Specialty
No3416A0800XTransportation ServicesAmbulanceAir TransportGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100239890AMedicaid
IN200318490AMedicaid
IN100269890BMedicaid
IN200378380AMedicaid
IN200713710AMedicaid
IN000000097671OtherANTHEM PIN
IN100269910AMedicaid
IN100269910AMedicaid
IN15T058Medicare Oscar/Certification