Provider Demographics
NPI:1184751273
Name:DECATUR MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DECATUR MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-876-2119
Mailing Address - Street 1:3122 BRETTWOOD CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-2425
Mailing Address - Country:US
Mailing Address - Phone:217-876-4040
Mailing Address - Fax:217-876-4075
Practice Address - Street 1:2875 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4233
Practice Address - Country:US
Practice Address - Phone:217-876-4040
Practice Address - Fax:217-876-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5870764OtherBLUE CROSS BLUE SHEILD
IL=========013Medicaid
IL=========013Medicaid