Provider Demographics
NPI:1831150119
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 1:210 MARIE LANGDON DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6388
Practice Address - Country:US
Practice Address - Phone:606-598-5104
Practice Address - Fax:606-598-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 1041C0700X, 207P00000X, 2085R0202X, 324500000X, 363A00000X, 363LF0000X, 367500000X
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100664020Medicaid
KY7100584470Medicaid
KY78905007Medicaid
KY7100427470Medicaid
KY74900804Medicaid
KY65934523Medicaid
KY7100644910Medicaid