Provider Demographics
NPI:1376841395
Name:MEMORIAL HOSPITAL OF SOUTH BEND
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF SOUTH BEND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3549
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:574-647-7167
Mailing Address - Fax:
Practice Address - Street 1:420 N NILES AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1918
Practice Address - Country:US
Practice Address - Phone:574-647-8400
Practice Address - Fax:574-647-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN005053273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100269890BMedicaid
15S058Medicare Oscar/Certification