1316470651 NPI number — MEMORIAL PHYSICIAN SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316470651 NPI number — MEMORIAL PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL PHYSICIAN SERVICES
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 EXPRESSCARE AT CHATHAM
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:
1316470651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 N 1ST ST
Provider Second Line Business Mailing Address:
MAILBOX 95
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62781-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-577-5368
Provider Business Mailing Address Fax Number:
217-757-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 N 1ST ST
Provider Second Line Business Practice Location Address:
MAILBOX 95
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62781-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-577-5368
Provider Business Practice Location Address Fax Number:
217-757-2021
Provider Enumeration Date:
04/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DOWELL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT MPS
Authorized Official Telephone Number:
217-757-7716

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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