Basic Information
| Provider Information | |||||||||
| NPI: | 1174526289 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMERON MEMORIAL COMMUNITY HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMERON HOME HEALTH CARE AND HOSPICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 E MAUMEE ST | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467032015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606652141 | ||||||||
| FaxNumber: | 2606658608 | ||||||||
| Practice Location | |||||||||
| Address1: | 416 E MAUMEE ST | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467032015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606652141 | ||||||||
| FaxNumber: | 2606658608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOMBA | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2606652141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAMERON MEMORIAL COMMUNITY HOSPITAL, INC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 05-005308-1 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1174526289 | 01 | IN | PECOS | OTHER | 200056150A | 05 | IN | MEDICAID | 000000097654 | 01 | IN | BLUE CROSS BLUE SHIELD PI | OTHER | 100263930A | 05 | IN | MEDICAID |