Basic Information
| Provider Information | |||||||||
| NPI: | 1255525721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HOSPITAL AND HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 NORTH MERIDIAN STREET | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125363943 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 NORTH MERIDIAN STREET | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125363943 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124822345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPNAY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CB3118 | 01 | IN | RAILROAD MEDICARE | OTHER |