Basic Information
| Provider Information | |||||||||
| NPI: | 1538114848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVIESS COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LAURELS OF DEKALB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 520 W LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467211063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
| FaxNumber: | 6147948826 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 W LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467211063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
| FaxNumber: | 6147948826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 0005741 | IN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 0005741 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100266430A | 05 | IN | MEDICAID | 313673677-001 | 01 | IN | BLUE CROSS BLUE SHIELD # | OTHER |