Provider Demographics
NPI:1285729210
Name:PROTESTANT MEMORIAL MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:PROTESTANT MEMORIAL MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-5606
Mailing Address - Street 1:4315 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5342
Mailing Address - Country:US
Mailing Address - Phone:618-257-5060
Mailing Address - Fax:618-257-6940
Practice Address - Street 1:4315 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5342
Practice Address - Country:US
Practice Address - Phone:618-257-5060
Practice Address - Fax:618-257-6940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0003103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL390635502002Medicaid
145102Medicare ID - Type Unspecified