Provider Demographics
NPI:1063426823
Name:MEMORIAL HEALTH SYSTEMS INC
Entity type:Organization
Organization Name:MEMORIAL HEALTH SYSTEMS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-231-3906
Mailing Address - Street 1:770 W GRANADA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5179
Mailing Address - Country:US
Mailing Address - Phone:386-231-4610
Mailing Address - Fax:386-231-3342
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-6000
Practice Address - Fax:386-231-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0404X
FL4201282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010186900Medicaid
FL1063426823OtherAETNA HMO
FL1063426823OtherAETNA PPO
FL1063426823OtherUHC
FL334OtherBLUE CROSS
FL1063426823OtherAETNA HMO
FL010186900Medicaid