Basic Information
| Provider Information | |||||||||
| NPI: | 1003821729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUNTINGTON MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARKVIEW HUNTINGTON HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5600 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737008 | ||||||||
| FaxNumber: | 2603737059 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 STULTS RD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603553304 | ||||||||
| FaxNumber: | 2603553346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2602669313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUNTINGTON MEMORIAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 282N00000X | 100268810A | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1500091 | 05 | NC | MEDICAID | 2414391 | 05 | OH | MEDICAID | 912781000 | 05 | FL | MEDICAID | 000000005189 | 01 | IN | MPLAN IDENTIFICATION # | OTHER | 100268810A | 05 | IN | MEDICAID | 304560283 | 05 | MI | MEDICAID | PAR0091N | 05 | AL | MEDICAID | 154510105 | 05 | AK | MEDICAID | 01300367 | 05 | KY | MEDICAID | 000000098130 | 01 | IN | INDIANA COMP. ID# | OTHER | 032126100 | 01 | IN | BLACK LUNG ID# | OTHER | 1516840 | 01 | NCPDP | OTHER | 0037648 | 05 | NJ | MEDICAID | 016138406 | 05 | MO | MEDICAID | 3072 | 01 | IN | PHP IDENTIFICATION # | OTHER | 000000098130 | 01 | IN | ANTHEM IDENTIFICATION # | OTHER | 10025091500 | 05 | NE | MEDICAID |