Basic Information
| Provider Information | |||||||||
| NPI: | 1245259878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKVIEW WABASH HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKVIEW WABASH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10501 CORPORATE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738406 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 JOHN KISSINGER DRIVE | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469921648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605633131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2602669313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 14-005094-1 | IN | N | Hospitals | General Acute Care Hospital | 282NC0060X | 06-005094-1 | IN | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | 18-005094-1 | IN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 036676500 | 01 | IN | BLACK LUNG | OTHER | 100270180A | 05 | IN | MEDICAID | 01340421 | 05 | KY | MEDICAID | 201277260A | 05 | IN | MEDICAID | 000000097837 | 01 | IN | ANTHEM BLUE CROSS | OTHER | 304685582 | 05 | MI | MEDICAID |