Healthcare Provider Details

I. General information

NPI: 1275640997
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: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MEMORIAL MEDICAL PKWY STE 2811
PALM COAST FL
32164-5999
US

IV. Provider business mailing address

PO BOX 730729
ORMOND BEACH FL
32173-0729
US

V. Phone/Fax

Practice location:
  • Phone: 386-671-4519
  • Fax:
Mailing address:
  • Phone: 386-671-4500
  • Fax: 386-672-9904

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 Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: CORY DOMAYER
Title or Position: VP
Credential:
Phone: 383-231-3906