Basic Information
| Provider Information | |||||||||
| NPI: | 1811922347 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANCHESTER MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065987008 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065981002 | ||||||||
| FaxNumber: | 6065987008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERKLIN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6065981035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 100075 | KY | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 100033950A | 01 | IN | INDIANA MEDICAID | OTHER | 65265 | 01 | KY | MEMORIAL EMPLOYEES | OTHER | 6280695 | 01 | KY | AETNA | OTHER | 1004431 | 05 | KY | MEDICAID | 180043 | 01 | KY | MEDICARE MANAGED CARE | OTHER | 87696 | 01 | OH | OHIO MEDICAID | OTHER | 30523000 | 01 | KY | BLACK LUNG | OTHER | 65265 | 01 | KY | ANTHEM BLUE CROSS | OTHER | 902088800 | 01 | KY | MEDICAID | OTHER | 5000038 | 01 | KY | UNITED HEALTHCARE | OTHER |