Provider Demographics
NPI:1720026743
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:MEMORIAL HOME HEALTH CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:LITTELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-334-6661
Mailing Address - Street 1:715 SOUTH TAFT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3200
Mailing Address - Country:US
Mailing Address - Phone:419-332-7321
Mailing Address - Fax:419-332-5875
Practice Address - Street 1:430 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-2142
Practice Address - Country:US
Practice Address - Phone:419-334-6626
Practice Address - Fax:419-547-9459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0614008Medicaid
OH0614008Medicaid