Basic Information
| Provider Information | |||||||||
| NPI: | 1902839293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUNBELT HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 149 HEALTH CARE LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841206 | ||||||||
| FaxNumber: | 4237841136 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 HEALTH CARE LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237842452 | ||||||||
| FaxNumber: | 4237841184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERKLIN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6065981035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 00000000-16 | TN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0447492 | 01 | TN | JOHN DEERE HEALTH | OTHER | 100020437 | 01 | TN | PHP COMPANIES | OTHER | 46166 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 0447492 | 01 | TN | PACIFICARE MCR | OTHER | 3075983 | 01 | TN | BLUECARE | OTHER | 3075983 | 01 | TN | TENNCARE SELECT | OTHER | 0447492 | 01 | TN | STERLING LIFE MCR | OTHER | 0447492 | 01 | TN | JOHN DEERE TENNCARE | OTHER | 087482900 | 01 | TN | FEDERAL BLACK LUNG | OTHER |