Healthcare Provider Details

I. General information

NPI: 1912137720
Provider Name (Legal Business Name): MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MEMORIAL DR STE 1
MANCHESTER KY
40962-9157
US

IV. Provider business mailing address

210 MARIE LANGDON DR
MANCHESTER KY
40962-6388
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-4524
  • Fax: 606-599-2554
Mailing address:
  • Phone: 606-598-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. SISSEL JACOB
Title or Position: CEO
Credential:
Phone: 606-598-5104