Basic Information
| Provider Information | |||||||||
| NPI: | 1154396604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SCOTT MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1451 N GARDNER ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471707751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127523456 | ||||||||
| FaxNumber: | 8127525884 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 N GARDNER ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471707751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127523456 | ||||||||
| FaxNumber: | 8127525884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOOLEY | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8127523456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 060047781 | IN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 100268930 | 05 | IN | MEDICAID |