Provider Demographics
NPI:1316008006
Name:MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JORRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:TREMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-729-4466
Mailing Address - Street 1:113 E WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2360
Mailing Address - Country:US
Mailing Address - Phone:989-725-6528
Mailing Address - Fax:989-723-9446
Practice Address - Street 1:826 W KING ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2120
Practice Address - Country:US
Practice Address - Phone:989-723-5211
Practice Address - Fax:989-723-9446
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207RG0100X, 207RH0003X, 208000000X, 208100000X, 2083X0100X, 363A00000X, 363LF0000X, 208D00000X
MI1060000059207RE0101X, 207V00000X, 207X00000X, 207YS0123X, 2084N0400X
MI106000059208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316008006Medicaid
MI080G810270OtherBLUE CROSS BLUE SHIELD
MI1316008006Medicaid
MICE7951Medicare PIN
MI080G810270OtherBLUE CROSS BLUE SHIELD
MI0N90910Medicare Oscar/Certification