Basic Information
| Provider Information | |||||||||
| NPI: | 1487662961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKVIEW HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKVIEW BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5600 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737008 | ||||||||
| FaxNumber: | 2603737059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737500 | ||||||||
| FaxNumber: | 2603738446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAFZIGER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP -- CFO | ||||||||
| AuthorizedOfficialTelephone: | 2603737008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKVIEW HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 060050201 | IN | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 462118-00 | 01 | IN | MAGELLAN PROVIDER NUMBER | OTHER | 100268480A | 05 | IN | MEDICAID |