Basic Information
| Provider Information | |||||||||
| NPI: | 1447206248 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERRY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PCMH WOUND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8885 SR 237 | ||||||||
| Address2: | |||||||||
| City: | TELL CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475862750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125477011 | ||||||||
| FaxNumber: | 8125470174 | ||||||||
| Practice Location | |||||||||
| Address1: | 8885 STATE ROAD 237 | ||||||||
| Address2: | |||||||||
| City: | TELL CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475868567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125477011 | ||||||||
| FaxNumber: | 8125470174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | HERWIG | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8125477011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 282NC0060X | 050050641 | IN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 100270000A | 05 | IN | MEDICAID | 65938318 | 05 | KY | MEDICAID |