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General NPI Number Information
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NPI Number | 1548540982
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Entity Type | Organization
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Legal Business Name | MEMORIAL MEDICAL CENTER (SIU)
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Dates
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Enumeration Date | 08/17/2011
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 701 N 1ST ST
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City | SPRINGFIELD
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State | IL
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Zip | 62702-3757
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Country | US
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Telephone | 217-545-4735
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Fax |
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Provider Business Mailing Address
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Address Line | 701 N 1ST ST.
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City | SPRINGFIELD
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State | IL
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Zip | 62794-9636
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | RESIDENT.
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Name | DR. TESFAYE TELILA
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Credential | M.D
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Telephone | 217-545-0182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273R00000X
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Taxonomy Name | Psychiatric Hospital Unit
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License Number |
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License Number State | IL
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