Basic Information
| Provider Information | |||||||||
| NPI: | 1194753103 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITAL OF INDIANA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GALLAHUE PSYCH ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19751 | ||||||||
| Address2: | PATIENT ACCOUNTS LOWER LEVEL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462190751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Practice Location | |||||||||
| Address1: | 7165 CLEARVISTA WAY | ||||||||
| Address2: | PSYCH PAVILION | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISCHER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3173554887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITALS OF IN INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | JCPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200042460A | 05 | IN | MEDICAID | CF9322 | 01 | IN | RAILROAD MEDICARE | OTHER | 202981-000 | 01 | IN | MAGELLAN | OTHER |