Basic Information
| Provider Information | |||||||||
| NPI: | 1548275134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBUS REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GARDEN VILLA - BLOOMINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 17TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123794441 | ||||||||
| FaxNumber: | 8123765963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S CURRY PIKE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391657 | ||||||||
| FaxNumber: | 8123356804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEATHERWAX | ||||||||
| AuthorizedOfficialFirstName: | MARLENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8123765205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 311Z00000X | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000098144 | 01 | IN | ANTHEM BLUE CROSS | OTHER | 100275040B | 05 | IN | MEDICAID |