Provider Demographics
NPI:1740355809
Name:MASSAC MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MASSAC MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-524-2176
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-0790
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-524-4131
Practice Address - Street 1:1204 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-0790
Practice Address - Country:US
Practice Address - Phone:618-524-2176
Practice Address - Fax:618-524-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001420261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143478Medicare ID - Type Unspecified
IL=========005Medicaid