Basic Information
Provider Information | |||||||||
NPI: | 1306141163 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENDRICKS COUNTY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HENDRICKS REGIONAL HEALTH BAINBRIDGE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SOUTHFIELD DR | ||||||||
Address2: | SUITE 1370 | ||||||||
City: | PLAINFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461684498 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178375571 | ||||||||
FaxNumber: | 3178375580 | ||||||||
Practice Location | |||||||||
Address1: | 1152 E US HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | BAINBRIDGE | ||||||||
State: | IN | ||||||||
PostalCode: | 461059604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655221889 | ||||||||
FaxNumber: | 7655223583 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2011 | ||||||||
LastUpdateDate: | 06/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KLAYER | ||||||||
AuthorizedOfficialFirstName: | GENI | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3178375571 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN, BSN, MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 2084N0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.