Basic Information
| Provider Information | |||||||||
| NPI: | 1982602934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH CARE SYSTEM INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HOSPITAL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1949 GUNBARREL RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234958550 | ||||||||
| FaxNumber: | 4234953780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1949 GUNBARREL RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234958550 | ||||||||
| FaxNumber: | 4234953780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEWTON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | CAROL | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4234957878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HEALTH CARE SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 0000000103 | TN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0049499 | 01 | TN | BCBS PROVIDER NUMBER | OTHER |