Provider Demographics
NPI:1881177756
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:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
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:574-647-1000
Mailing Address - Fax:
Practice Address - Street 1:3220 BEACON PARKWAY
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-999-8788
Practice Address - Fax:574-999-8781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300031565Medicaid
IN300032573Medicaid