Basic Information
| Provider Information | |||||||||
| NPI: | 1124446034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCHENRY COUNTY CRISIS PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 DOTY ROAD | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153382910 | ||||||||
| FaxNumber: | 8153382912 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 DOTY ROAD | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153382910 | ||||||||
| FaxNumber: | 8153382912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TOMLINSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CIO & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8157885831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.