Basic Information
| Provider Information | |||||||||
| NPI: | 1609510502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882624 | ||||||||
| FaxNumber: | 2177577550 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E CARPENTER ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883948 | ||||||||
| FaxNumber: | 2175273209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2022 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/PHYSICIAN BILLING | ||||||||
| AuthorizedOfficialTelephone: | 2175882626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 1033171343 | 01 | IL | MMC NPI | OTHER |