Basic Information
| Provider Information | |||||||||
| NPI: | 1518962109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKVIEW HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARKVIEW HOME HEALTH AND HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5600 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737008 | ||||||||
| FaxNumber: | 2603737059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CAREW ST | ||||||||
| Address2: | STE 6 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739800 | ||||||||
| FaxNumber: | 2603739949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2603738407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKVIEW HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 050083471 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 200121480C | 05 | IN | MEDICAID | 200034360A | 05 | IN | MEDICAID | 200121480B | 05 | IN | MEDICAID | 200034360B | 05 | IN | MEDICAID | 000000097668 | 01 | ANTHEM | OTHER | 200034360C | 05 | IN | MEDICAID | 200121480A | 05 | IN | MEDICAID | 200034360E | 05 | IN | MEDICAID | 200121480D | 05 | IN | MEDICAID | 700011 | 01 | BLACK LUNG | OTHER |