Provider Demographics
NPI:1558665752
Name:MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SISSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-598-5104
Mailing Address - Street 1:210 MARIE LANGDON DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6388
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:
Practice Address - Street 1:53 QUEENDALE CTR STE 2
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:KY
Practice Address - Zip Code:40913-8621
Practice Address - Country:US
Practice Address - Phone:606-598-5135
Practice Address - Fax:606-599-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100312760Medicaid
183484Medicare PIN