Basic Information
| Provider Information | |||||||||
| NPI: | 1104179415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL PHYSICIAN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1602 W LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172437200 | ||||||||
| FaxNumber: | 2172436165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOWELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MPS | ||||||||
| AuthorizedOfficialTelephone: | 2177883342 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 148906 | 01 | RHC MEDICARE PTAN | OTHER |