Basic Information
| Provider Information | |||||||||
| NPI: | 1285831396 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DECATUR COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DECATUR COUNTY MEMORIAL HOSPITAL SWING BED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 720 N LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472401327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126634331 | ||||||||
| FaxNumber: | 8126639738 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472401327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126634331 | ||||||||
| FaxNumber: | 8126639738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUCKEL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8126634331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 07-004714-1 | IN | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 100268720A | 05 | IN | MEDICAID |