Basic Information
| Provider Information | |||||||||
| NPI: | 1417499674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HEALTH ST. CHARLES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129966050 | ||||||||
| FaxNumber: | 8129966051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 SAINT CHARLES ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475469172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129966050 | ||||||||
| FaxNumber: | 8129966051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129960507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.