Healthcare Provider Details

I. General information

NPI: 1366559080
Provider Name (Legal Business Name): MEMORIAL HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 STERTHAUS AVE
ORMOND BEACH FL
32174-5131
US

IV. Provider business mailing address

PO BOX 730729
ORMOND BEACH FL
32173-0729
US

V. Phone/Fax

Practice location:
  • Phone: 386-671-4500
  • Fax: 386-672-9904
Mailing address:
  • Phone: 386-671-4500
  • Fax: 386-672-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: CORY DOMAYER
Title or Position: CFO
Credential:
Phone: 386-231-3909