Basic Information
| Provider Information | |||||||||
| NPI: | 1205180056 | ||||||||
| 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: | 1600 W WALNUT ST | ||||||||
| Address2: | EAST WING, 3RD FLOOR | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172455437 | ||||||||
| FaxNumber: | 2172433113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2012 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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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 |
No ID Information.