Basic Information
| Provider Information | |||||||||
| NPI: | 1346292737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DECATUR COUNTY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | SOUTH SHORE HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 N LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472401327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126634331 | ||||||||
| FaxNumber: | 8476796236 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 TYLER STREET | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198867070 | ||||||||
| FaxNumber: | 2198860810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCKINNEY | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 8126634331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 14-000369-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100275190B | 05 | IN | MEDICAID | 100275190 | 05 | IN | MEDICAID |