Basic Information
| Provider Information | |||||||||
| NPI: | 1083778633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH CARE SYSTEM INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HOSPITAL HIXSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 HAMILL RD | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373436614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234957100 | ||||||||
| FaxNumber: | 4234956312 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 HAMILL RD | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373436614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234957100 | ||||||||
| FaxNumber: | 4234956312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUTTON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4234958488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000071 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00236662A | 05 | GA | MEDICAID | 0440091 | 05 | TN | MEDICAID |