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General NPI Number Information
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NPI Number | 1497807689
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Entity Type | Organization
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Legal Business Name | WABASH MEMORIAL HOSPITAL ASSOCIATION
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 05/01/2008
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Provider Practice Location Address
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Address Line | 1501 N WATER ST
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City | DECATUR
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State | IL
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Zip | 62526-4441
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Country | US
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Telephone | 217-425-9642
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Fax | 217-542-0134
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Provider Business Mailing Address
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Address Line | 1501 N WATER ST PO BOX 1340
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City | DECATUR
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State | IL
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Zip | 62526-4441
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Country | US
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Telephone | 217-425-9642
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Fax | 217-542-0134
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Authorized Official
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Title or Position | CLINIC PHYSICIAN
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Name | DR. VENITA EDWARDS-TALLEY
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Credential | M.D.
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Telephone | 217-425-9642
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 36117078
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License Number State | IL
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