Basic Information
| Provider Information | |||||||||
| NPI: | 1477626398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITALS OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHADELAND FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3826 SOLUTIONS CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 N SHADELAND AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173553232 | ||||||||
| FaxNumber: | 3173556042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | KIRKHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3173554887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITALS OF INDIANA INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100121170A | 05 | IN | MEDICAID | 5942684 | 01 | IN | AETNA | OTHER | 000000226100 | 01 | IN | ANTHEM | OTHER | 000000107139 | 01 | IN | ANTHEM | OTHER |