Organization Active NPI

Memorial Hospital

Rural Health Clinic/Center
Chester, IL

National Provider Identifier

1629469002

Registry record updated Oct 11, 2024

On this page

Key facts
NPPES NPI Registry
Medicare participation
National Provider Directory
Ownership & related parties
Practitioners & affiliated clinicians
NPI Registry JSON
Other providers in Chester, IL
Sources for this page

Key facts

NPPES NPI Registry

Primary specialty: Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name: MEMORIAL HOSPITAL
Practice address: 1900 State St
Chester, IL 62233-1116
Phone: (618) 826-2388
NPI assigned: Feb 6, 2015
Last updated: Oct 11, 2024By the provider in NPPES
Organization subpart: No

NPPES NPI Registry

Updated by the provider on Oct 11, 2024

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

Authorized official

Name: Mrs. Morgan Bendorf
Title: Cfo
Phone: (618) 826-4581

Specialties & licenses 13

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	207Q00000X	036-051292	IL
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	207Q00000X	036-052369	IL
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	207Q00000X	036-130378	IL
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	207Q00000X	036-087561	IL
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	208600000X	036-127160	IL
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP	208600000X	036-046019	IL
Rural Health Clinic/Center	261QR1300X			Primary
Critical Access Hospital	282NC0060X	0001495	IL
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP	363A00000X	085-003568	IL
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP	363A00000X	085-003575	IL
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP	363L00000X	209-009681	IL
Certified Registered Nurse AnesthetistGroup: 193200000X MULTI-SPECIALTY GROUP	367500000X	041-149926	IL
Certified Registered Nurse AnesthetistGroup: 193200000X MULTI-SPECIALTY GROUP	367500000X	209-009387	IL

Addresses

Primary practice location

1900 State St
Chester, IL 62233-1116

Mailing address

1900 State St
Chester, IL 62233-1116
Phone (618) 826-4581

Other names 1

Randolph Hospital District Other name

Medicare participation

Medicare enrollment files

Medicare fee-for-service enrollment: Enrolled in IL

Enrollment records 1

Enrollment ID	State	Provider type	PAC ID	Details
O20150414000018	IL	Part A Provider - Rural Health Clinic	5294649372	Practice locations: Chester, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629469002. Details of each certification follow.

CCN 148543 Rural health clinic · Active · Details

Rural health clinic certification: CCN 148543

Legal name: MEMORIAL HOSPITAL
Certification status: Active
Provider type (POS): Rural health clinic
Participating since: Jun 1, 2015
Last certification: Mar 21, 2023
Ownership / control type: 2B
Organization structure: CorporationProprietary
Incorporated: Mar 14, 1962 in IL
Enrollment address: 1900 State St
Chester, IL 62233-1116
Related CCNs: 141338

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

Memorial Hospital
- Critical Access Hospital
- Chester, IL
- NPI 1851390132
Parent provider
Provider of Services

Other NPIs with the same Medicare PAC ID 3

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

Memorial Hospital
- Institutional Pharmacy
- Chester, IL
- NPI 1023603289
5294649372
Same PAC ID
Memorial Hospital
- Rural Health Clinic/Center
- Steeleville, IL
- NPI 1225429566
5294649372
Same PAC ID
Memorial Hospital
- Critical Access Hospital
- Chester, IL
- NPI 1851390132
5294649372
Same PAC ID

National Provider Directory

Tax ID family: Memorial Hospital PC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Memorial Hospital
- Institutional Pharmacy
- Chester, IL
- NPI 1023603289
NPD tax ID
Memorial Hospital
- Rural Health Clinic/Center
- Steeleville, IL
- NPI 1225429566
NPD tax ID
Memorial Hospital
- Emergency Medical Services (Emergency Medicine) Physician
- Chester, IL
- NPI 1790209518
NPD tax ID
Memorial Hospital of Chester
- Physical Therapy Clinic/Center
- Chester, IL
- NPI 1861757361
NPD tax ID

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.

Name	Role	Since	Share
Mary Sulser Individual	Corporate DirectorBoard Member	Jul 6, 2015	100%
Michael Vasquez Individual	Corporate DirectorBoard Member	Jun 1, 2015	100%
Mary Brown Individual	Corporate DirectorBoard Member	Jul 6, 2015	100%
Grant Deterding Individual	Corporate DirectorBoard Member	Jul 28, 2017	100%
Evelyn Schuwerk Individual	Corporate DirectorBoard Member	Jun 1, 2015	100%
Brett a Bollmann Individual	Corporate OfficerCeo	Sep 7, 2017
Brett a Bollmann Individual	W-2 Managing EmployeeCeo	Jun 1, 2015	100%
Memorial Hospital Organization, Chester, IL	5% Or Greater Direct Ownership Interest	Jun 1, 2015	100%
Cassandra Parker Individual	Corporate DirectorBoard Member	Aug 1, 2022	100%
Morgan K Bendorf Individual	Corporate OfficerChief Financial Officer	Oct 1, 2017
Morgan K Bendorf Individual	W-2 Managing EmployeeCfo	Oct 1, 2017	100%
Gregory Crain Individual	Corporate DirectorBoard Member	Aug 1, 2022	100%
Thomas Search Individual	Corporate DirectorBoard Member	Jun 1, 2015	100%
Daniel R Colvis Individual	Corporate DirectorBoard Member	Jun 1, 2015	100%

Owners & managing parties with NPI records 3

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

Memorial Hospital
- Institutional Pharmacy
- Chester, IL
- NPI 1023603289
5% Or Greater Direct Ownership Interest
CMS ownership
Memorial Hospital
- Rural Health Clinic/Center
- Steeleville, IL
- NPI 1225429566
5% Or Greater Direct Ownership Interest
CMS ownership
Memorial Hospital
- Critical Access Hospital
- Chester, IL
- NPI 1851390132
5% Or Greater Direct Ownership Interest
CMS ownership

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Facility	Type	Role	Since
Memorial HospitalSteeleville, IL, CCN 148542	Rural health clinic	5% Or Greater Direct Ownership Interest (100%)	Jun 1, 2015

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Memorial Hospital
- Rural Health Clinic/Center
- Steeleville, IL
- NPI 1225429566
5% Or Greater Direct Ownership Interest
CMS ownership

Facilities with the same owner 1

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

Memorial Hospital
- Rural Health Clinic/Center
- Steeleville, IL
- NPI 1225429566
Memorial Hospital
CMS ownership

Practitioners & affiliated clinicians

Practitioners 1

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.

Robert R Bell, MD
- Orthopaedic Hand Surgery Physician
- Saint Louis, MO
- NPI 1851371082
NPD (past)

NPI Registry JSON

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

{
    "created_epoch": "1423180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728604800000",
    "number": "1629469002",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 STATE ST",
            "city": "CHESTER",
            "state": "IL",
            "postal_code": "622331116",
            "telephone_number": "618-826-4581"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 STATE ST",
            "city": "CHESTER",
            "state": "IL",
            "postal_code": "622331116",
            "telephone_number": "618-826-2388"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-06",
        "last_updated": "2024-10-11",
        "certification_date": "2024-10-11",
        "status": "A",
        "authorized_official_last_name": "BENDORF",
        "authorized_official_first_name": "MORGAN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "618-826-4581",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036-051292",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036-052369",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036-130378",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036-087561",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "IL",
            "license": "036-127160",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "IL",
            "license": "036-046019",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "IL",
            "license": "0001495",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085-003568",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085-003575",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "IL",
            "license": "209-009681",
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "IL",
            "license": "041-149926",
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "IL",
            "license": "209-009387",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Randolph Hospital District",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Chester, IL

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.