Basic Information
| Provider Information | |||||||||
| NPI: | 1346261971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HOSPITALS OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENDLETON MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1251 HUNTZINGER BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PENDLETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460649493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984567 | ||||||||
| FaxNumber: | 7652984567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 HUNTZINGER BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PENDLETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460649493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984567 | ||||||||
| FaxNumber: | 7652984567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | KIRKHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3173555822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | DC6886 | 01 | IN | RR MEDICARE | OTHER | 200849300A | 05 | IN | MEDICAID |