Basic Information
| Provider Information | |||||||||
| NPI: | 1154326098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERRY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERRY COUNTY MEMORIAL HOSPITAL HOME CARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8885 SR 237 | ||||||||
| Address2: | |||||||||
| City: | TELL CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475862750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125477011 | ||||||||
| FaxNumber: | 8125470174 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 US HIGHWAY 66 E | ||||||||
| Address2: | |||||||||
| City: | TELL CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125477011 | ||||||||
| FaxNumber: | 8125470229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8125470146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PERRY COUNTY MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 005344 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100264720 | 05 | IN | MEDICAID |