Basic Information
| Provider Information | |||||||||
| NPI: | 1063411551 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENDRICKS COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HENDRICKS REGIONAL HEALTH IMMEDIATE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8244 E US HIGHWAY 36 | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461239575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172727500 | ||||||||
| FaxNumber: | 3172727515 | ||||||||
| Practice Location | |||||||||
| Address1: | 8244 E US HIGHWAY 36 | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461239575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172727500 | ||||||||
| FaxNumber: | 3172727515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMALLWOOD | ||||||||
| AuthorizedOfficialFirstName: | MARIJANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR IMMEDIATE CARE | ||||||||
| AuthorizedOfficialTelephone: | 3172723688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HENDRICKS REGIONAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, MSN, NE-BC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 100442010 | 05 | IN | MEDICAID |