1609879097 NPI number — DECATUR MEMORIAL HOSPITAL

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 1609879097 NPI number — DECATUR MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DECATUR 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:
PHYSICIAN'S PLAZA PHARMACY
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:
1609879097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 N EDWARD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526-4163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-876-6252
Provider Business Mailing Address Fax Number:
217-876-6215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N EDWARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-876-6252
Provider Business Practice Location Address Fax Number:
217-876-6215
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WELCH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHRMCY MGR
Authorized Official Telephone Number:
217-876-6252

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054011351 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2017369 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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