Basic Information
| Provider Information | |||||||||
| NPI: | 1104871664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNION HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WCCH-CAYUGA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2505 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N DIVISION STREET | ||||||||
| Address2: | |||||||||
| City: | CAYUGA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654929042 | ||||||||
| FaxNumber: | 7654929044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | PALLUTCH | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8122387000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNION HOSPITAL INCORPORATED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 153876 | 01 | IN | RIVERBEND | OTHER | 200074840G | 05 | IN | MEDICAID |