Basic Information
| Provider Information | |||||||||
| NPI: | 1851695480 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH CARE SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HEART INSTITUTE, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1366 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374011366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236972128 | ||||||||
| FaxNumber: | 4236972153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 CITICO AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236972000 | ||||||||
| FaxNumber: | 4236972118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARMER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4236972103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HEALTH CARE SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1522630 | 05 | TN | MEDICAID |