Basic Information
Provider Information | |||||||||
NPI: | 1295732188 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DECATUR COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 N. LINCOLN ST | ||||||||
Address2: |   | ||||||||
City: | GREENSBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 472401398 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8126634331 | ||||||||
FaxNumber: | 8126631299 | ||||||||
Practice Location | |||||||||
Address1: | 718 N. LINCOLN ST | ||||||||
Address2: |   | ||||||||
City: | GREENSBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 472401348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8126620588 | ||||||||
FaxNumber: | 8126635932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 01/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCKINNEY | ||||||||
AuthorizedOfficialFirstName: | REX | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT//CEO | ||||||||
AuthorizedOfficialTelephone: | 8126634331 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 100268720C | 05 | IN |   | MEDICAID | 200220600A | 05 | IN |   | MEDICAID |