Healthcare Provider Details

I. General information

NPI: 1477633766
Provider Name (Legal Business Name): PROTESTANT MEMORIAL MEDICAL CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7750
  • Fax:
Mailing address:
  • Phone: 618-233-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0001461
License Number StateIL

VIII. Authorized Official

Name: MR. JOE H LANIUS
Title or Position: VICE PRESIDENT, FINANCE
Credential:
Phone: 618-257-5648