1063414233 NPI number — MEMORIAL HOSPITAL

Table of content: (NPI 1063414233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063414233 NPI number — MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEMORIAL HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063414233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
826 W KING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWOSSO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48867-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-723-5211
Provider Business Mailing Address Fax Number:
989-723-5274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 W KING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWOSSO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-723-5211
Provider Business Practice Location Address Fax Number:
989-723-5274
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TREMAIN
Authorized Official First Name:
JORRI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
989-729-4466

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  1060000059 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: M004774 . This is a "CHAMPUS IN/OUTPATIENT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 00058 . This is a "INPATIENT/OUTPATIENT/PSYC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0010013 . This is a "HEALTH PLUS IN/OUT PATIEN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 301557687 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5000009 . This is a "PHP IN/OUTPATIENT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 405171252 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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