Healthcare Provider Details

I. General information

NPI: 1285729210
Provider Name (Legal Business Name): PROTESTANT MEMORIAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 MEMORIAL DR
BELLEVILLE IL
62226-5342
US

IV. Provider business mailing address

4315 MEMORIAL DR
BELLEVILLE IL
62226-5342
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-5060
  • Fax: 618-257-6940
Mailing address:
  • Phone: 618-257-5060
  • Fax: 618-257-6940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0003103
License Number StateIL

VIII. Authorized Official

Name: MS. JANE GUSMANO
Title or Position: VICE PRESIDENT
Credential:
Phone: 618-257-5606