Basic Information
| Provider Information | |||||||||
| NPI: | 1215928536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERRY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERRY COUNTY FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8885 STATE ROAD 237 | ||||||||
| Address2: | |||||||||
| City: | TELL CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475868567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125477011 | ||||||||
| FaxNumber: | 8125479543 | ||||||||
| Practice Location | |||||||||
| Address1: | 18485 STATE RD 37 | ||||||||
| Address2: | |||||||||
| City: | LEOPOLD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475518072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128433038 | ||||||||
| FaxNumber: | 8128433084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | HERWIG | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8125470170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 000000371434 | 01 | IN | ANTHEM | OTHER | 65944290 | 05 | KY | MEDICAID | 78904927 | 05 | KY | MEDICAID | 200531240A | 05 | IN | MEDICAID | 15D1043196 | 01 | IN | CLIA | OTHER |