Basic Information
| Provider Information | |||||||||
| NPI: | 1497785836 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745837111 | ||||||||
| FaxNumber: | 5745831703 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745837111 | ||||||||
| FaxNumber: | 5745831703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5745837111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 06-010028-1 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000000097810 | 01 | IN | HOME CARE BLUE CROSS | OTHER | 200153690 | 05 | IN | MEDICAID | 200196870 | 05 | IN | MEDICAID |