Provider Demographics
NPI:1720172307
Name:DECATUR MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DECATUR MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-876-2107
Mailing Address - Street 1:2300 N. EDWARD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-2264
Mailing Address - Fax:217-876-2261
Practice Address - Street 1:2870 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3234
Practice Address - Country:US
Practice Address - Phone:217-876-6770
Practice Address - Fax:217-876-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000354251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid
IL=========005Medicaid