Provider Demographics
NPI:1902134521
Name:MEMORIAL HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEM, INC.
Other - Org Name:MEMORIAL'S PRENATAL CLINIC @ OLIVE STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3549
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:244 S OLIVE ST
Practice Address - Street 2:SUITE E
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2100
Practice Address - Country:US
Practice Address - Phone:574-647-1600
Practice Address - Fax:574-237-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000186A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty