Healthcare Provider Details

I. General information

NPI: 1255471827
Provider Name (Legal Business Name): MEMORIAL HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

IV. Provider business mailing address

210 MARIE LANGDON DR
MANCHESTER KY
40962-6388
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5104
  • Fax: 606-598-1688
Mailing address:
  • Phone: 606-598-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900236
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateKY

VIII. Authorized Official

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