Basic Information
| Provider Information | |||||||||
| NPI: | 1346451465 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC.. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JASPER PEDIATRICS OF MEMORIAL HOSPITAL AND HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 150 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475470150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129967918 | ||||||||
| FaxNumber: | 8129961644 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 W 13TH ST | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475461855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129967918 | ||||||||
| FaxNumber: | 8129961644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129960503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01038423A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200048850P | 05 | IN | MEDICAID |