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General NPI Number Information
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NPI Number | 1649589268
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Entity Type | Organization
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Legal Business Name | MEMORIAL HOSPITAL OF CARBONDALE
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Dates
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Enumeration Date | 09/30/2010
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Last Update Date | 09/30/2010
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Provider Practice Location Address
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Address Line | 405 W JACKSON ST
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City | CARBONDALE
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State | IL
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Zip | 62901-1462
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Country | US
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Telephone | 618-549-0721
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Fax | 618-529-0431
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Provider Business Mailing Address
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Address Line | 405 W JACKSON ST
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City | CARBONDALE
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State | IL
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Zip | 62901-1462
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Country | US
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Telephone | 618-549-0721
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Fax | 618-529-0431
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Authorized Official
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Title or Position | NURSE PRACTITIONER, PRE-ANESTHESIA
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Name | MRS. AMY MARIE SURBURG
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Credential | ANP-BC
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Telephone | 618-549-0721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 209008246
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License Number State | IL
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