Healthcare Provider Details

I. General information

NPI: 1548540982
Provider Name (Legal Business Name): MEMORIAL MEDICAL CENTER (SIU)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62702-3757
US

IV. Provider business mailing address

701 N 1ST ST.
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-4735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. TESFAYE TELILA
Title or Position: RESIDENT.
Credential: M.D
Phone: 217-545-0182