Basic Information
| Provider Information | |||||||||
| NPI: | 1073886560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEKALB MEMORIAL HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | DEKALB HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 623 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467060623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 E 7TH ST | ||||||||
| Address2: | SUITE G | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609202000 | ||||||||
| FaxNumber: | 2609202005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | POLKOW | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2609254600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100104110I | 05 | IN | MEDICAID |