NPIMap

Organization Active NPI

Memorial Hospital Inc.

Doing business as AdventHealth Manchester

  • Rural Health Clinic/Center
  • Manchester, KY
National Provider Identifier
1255471827
Registry record updated Feb 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
900236 Issued in KY
Legal business name
MEMORIAL HOSPITAL INC.
Doing business as
AdventHealth Manchester
Practice address
56 Marie Langdon Dr
Manchester, KY 40962-6329
Phone
(606) 598-5104
Fax
(606) 598-1688
NPI assigned
Feb 6, 2007
Last updated
Feb 9, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Sissel Jacob
Title
President/Ceo
Phone
(606) 598-5104

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 900236 KY Primary
Family Nurse Practitioner 363LF0000X
Family Medicine Physician 207Q00000X
Internal Medicine Physician 207R00000X
Obstetrics & Gynecology Physician 207V00000X KY
Pediatrics Physician 208000000X KY

Addresses

Primary practice location

56 Marie Langdon Dr
Manchester, KY 40962-6329

Mailing address

210 Marie Langdon Dr
Manchester, KY 40962-6388
Phone (606) 598-5104

Other identifiers 3

IdentifierTypeStateIssuer
CC2941OtherRR MEDICARE
7100339170MedicaidKY
31001134MedicaidKY

Other names 1

  • AdventHealth Manchester Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20041103001183 KY Part B Supplier - Clinic/Group Practice 4486616141 Receives reassigned benefits from 129 practitioners
20 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pineville, KY; Somerset, KY; Oneida, KY; MC Kee, KY; Manchester, KY; London, KY; Corbin, KY; Beverly, KY
O20100305000639 KY Part A Provider - Rural Health Clinic 4486616141 Practice locations: Manchester, KY
O20141210002155 KY Part B Supplier - Clinic/Group Practice 4486616141 Receives reassigned benefits from 79 practitioners
Practice locations: Annville, KY; Corbin, KY; Hyden, KY; London, KY; Manchester, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1255471827. Details of each certification follow.

Rural health clinic certification: CCN 183468

Legal name
MEMORIAL HOSPITAL, INC.
Doing business as
ADVENTHEALTH MANCHESTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 5, 2010
Last certification
Jun 13, 2017
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 3, 1917 in KY
Enrollment address
56 Marie Langdon Dr
Manchester, KY 40962-6329
Related CCNs
180043

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 20

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 20

National Provider Directory

National Provider Directory

Locations

96 Highway 3444
Annville, KY 40402
Phone (606) 364-5197

100 Professional Dr
Ste 1
London, KY 40741
Phone (606) 677-2913

102 Professional Dr
London, KY 40741
Phone (606) 598-4537

102 Professional Dr
#3
London, KY 40741
Phone (606) 864-2788

102 Professional Dr
Ste 1
London, KY 40741
Phone (606) 599-4080

1380 Highway 192 E
Ste A
London, KY 40741
Phone (606) 330-0050

250 Richmond Rd
Manchester, KY 40962
Phone (606) 598-1969

401 Memorial Dr
Manchester, KY 40962
Phone (606) 598-4384

94 Marie Langdon Dr
Ste 4
Manchester, KY 40962
Phone (606) 598-7900

940 W Main St
Unit B
Mount Vernon, KY 40456
Phone (606) 256-9756

43 Cranberry Ln
#119
Delbarton, WV 25670
Phone (304) 475-4010

155 E 2nd Ave
Williamson, WV 25661
Phone (304) 235-3010

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Alan Guyton, Jr Individual Corporate OfficerCfo SE Region Apr 30, 2020
James Phillips Individual Corporate Director Jan 1, 2010
Anita F Cornett Individual Corporate DirectorBoard Member Jan 1, 2019
Peter Weber Individual Corporate DirectorBoard Member Jan 1, 2019
W-2 Managing EmployeePresident/Ceo Nov 29, 2021
Reecia Samples Individual Corporate DirectorBoard Member Jan 1, 2019
Daniel O Camacho Individual Corporate DirectorDirector/Cfo Jul 21, 2019
W-2 Managing EmployeeVice President/Cfo Jul 21, 2019
Steve Rose Individual Corporate DirectorBoard Member Jan 1, 2019
Marshall B House Individual Corporate Director Jan 1, 2010
Rajiv M Naval-Srinivas Individual Corporate OfficerDr Jan 1, 2020
Gregory C. Wilkens Individual Corporate DirectorBoard Member Jul 31, 2020
Charles Stone Individual Corporate DirectorBoard Member Jan 1, 2019
Adventist Health System Sunbelt Inc Organization, Altamonte Springs, FL Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1982 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 34

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 34

Practitioners & affiliated clinicians

Practitioners 150

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 150

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675900800000",
    "number": "1255471827",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "210 MARIE LANGDON DR",
            "city": "MANCHESTER",
            "state": "KY",
            "postal_code": "409626388",
            "telephone_number": "606-598-5104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "56 MARIE LANGDON DR",
            "city": "MANCHESTER",
            "state": "KY",
            "postal_code": "409626329",
            "telephone_number": "606-598-5104",
            "fax_number": "606-598-1688"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2023-02-09",
        "certification_date": "2023-02-09",
        "status": "A",
        "authorized_official_last_name": "JACOB",
        "authorized_official_first_name": "SISSEL",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "606-598-5104",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "KY",
            "license": "900236",
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "KY",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "CC2941",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100339170",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31001134",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AdventHealth Manchester",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manchester, KY

Sources for this page

Verify at the official NPI Registry.