Basic Information
| Provider Information | |||||||||
| NPI: | 1730194259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTEGRA HOSPITAL WOODSTOCK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153382500 | ||||||||
| FaxNumber: | 8153343948 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 DOTY RD | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600987509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153382500 | ||||||||
| FaxNumber: | 8153343948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | TOMLINSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CIO & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8157885831 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0001503 | IL | N | Hospitals | General Acute Care Hospital | 282N00000X | 0004606 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1819 | 01 | IL | BLUECROSS SUBSTANCE ABUSE | OTHER | 79 | 01 | IL | BLUE CROSS | OTHER |