Basic Information
| Provider Information | |||||||||
| NPI: | 1275732950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WITHAM MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINEKNOLL REHABILITATION CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9480 PRIORITY WAY WEST DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462401470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178181240 | ||||||||
| FaxNumber: | 3178181022 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 N MIDDLE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473948102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655845084 | ||||||||
| FaxNumber: | 7655847454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAVERMAN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7654858100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 11-000532-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100267180 | 05 | IN | MEDICAID |