Basic Information
| Provider Information | |||||||||
| NPI: | 1336632280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | EDGERTON FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | HICKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435261250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195425566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 S. WEST STREET | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192982478 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | ZACHRICH | ||||||||
| AuthorizedOfficialFirstName: | JANEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4195425566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 35090360 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.