Healthcare Provider Details

I. General information

NPI: 1902134521
Provider Name (Legal Business Name): MEMORIAL HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 S OLIVE ST SUITE E
SOUTH BEND IN
46619-2100
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1600
  • Fax: 574-237-6069
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number09000186A
License Number StateIN

VIII. Authorized Official

Name: MR. JEFFREY P. COSTELLO
Title or Position: VP/CFO
Credential:
Phone: 574-647-3549