Basic Information
| Provider Information | |||||||||
| NPI: | 1205844495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITLEY MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARKVIEW WHITLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5600 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737008 | ||||||||
| FaxNumber: | 2603737059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 E STATE ROAD 205 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602489302 | ||||||||
| FaxNumber: | 2602489107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP -- CFO | ||||||||
| AuthorizedOfficialTelephone: | 2602669313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITLEY MEMORIAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 282N00000X | 06-005090-1 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000000098126 | 01 | IN | INDIANA COMP. ID# | OTHER | 9422664 | 05 | OH | MEDICAID | 4744 | 01 | IN | PHP IDENTIFICATION # | OTHER | 03697300 | 01 | IN | BLACK LUNG ID# | OTHER | 1509946 | 01 | NCPDP | OTHER | 100268830A | 05 | IN | MEDICAID | 304608369 | 05 | MI | MEDICAID | 000000004969 | 01 | IN | MPLAN IDENTIFICATION # | OTHER | 01300664 | 05 | KY | MEDICAID | 351965665-001 | 01 | IN | CHAMPUS IDENTIFICATION # | OTHER | 000000098126 | 01 | IN | ANTHEM IDENTIFICATION # | OTHER | 404608378 | 05 | MI | MEDICAID |