Basic Information
Provider Information | |||||||||
NPI: | 1508054206 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL HOSPITAL AND HEALTH CARE CENTER HUNTINGBURG CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1028 | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475471028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8129968476 | ||||||||
FaxNumber: | 8129968497 | ||||||||
Practice Location | |||||||||
Address1: | 407 E 22ND ST | ||||||||
Address2: |   | ||||||||
City: | HUNTINGBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 475428964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8126833612 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2007 | ||||||||
LastUpdateDate: | 07/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SNOWDEN | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 8129962345 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100108380A | 05 | IN |   | MEDICAID |