Basic Information
| Provider Information | |||||||||
| NPI: | 1558443077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARTIN COUNTY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475462514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129960299 | ||||||||
| FaxNumber: | 8129968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 229 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SHOALS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475815501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122472733 | ||||||||
| FaxNumber: | 8122472373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129960507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPTIAL OF INDIANA INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200298610A | 05 | IN | MEDICAID | CB3118 | 01 | IN | RAILROAD MEDICARE | OTHER |