Basic Information
| Provider Information | |||||||||
| NPI: | 1942317656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MICHIGAN AVE | ||||||||
| Address2: | P.O. BOX 7013 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747537541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747537541 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | GAY | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5747531385 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 17-005066-1 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 200003920 | 05 | IN | MEDICAID | 201345470 | 05 | IN | MEDICAID |