Basic Information
| Provider Information | |||||||||
| NPI: | 1194829580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123503719 | ||||||||
| FaxNumber: | 9123503948 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123502324 | ||||||||
| FaxNumber: | 9123505824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 05/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | DOW | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9123508613 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 025-377 | GA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 001216 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 10006521 | 01 | GA | MEDICAID CMO | OTHER | 117736 | 05 | SC | MEDICAID | 00001273A | 05 | GA | MEDICAID | 456640 | 05 | SC | MEDICAID | 486 | 01 | GA | MEDICAID CMO | OTHER | 091693500 | 05 | FL | MEDICAID |