Basic Information
| Provider Information | |||||||||
| NPI: | 1568017481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANESTHESIA PROFESSIONAL FEES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882626 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2175882626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 453930 | 01 | IL | MEDICARE PTAN | OTHER |