Basic Information
| Provider Information | |||||||||
| NPI: | 1114296621 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883000 | ||||||||
| FaxNumber: | 2177885546 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883000 | ||||||||
| FaxNumber: | 2177885546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEELER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 2177883300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 146002528 | IL | Y | Hospitals | General Acute Care Hospital |
No ID Information.