Healthcare Provider Details

I. General information

NPI: 1922115914
Provider Name (Legal Business Name): MEMORIAL HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 205
DAYTONA BEACH FL
32117-5169
US

IV. Provider business mailing address

770 W GRANADA BLVD STE 203
ORMOND BEACH FL
32174-5179
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-3530
  • Fax:
Mailing address:
  • Phone: 863-231-4252
  • Fax: 386-676-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CORY DOMAYER
Title or Position: CFO
Credential:
Phone: 386-231-3906