Basic Information
Provider Information | |||||||||
NPI: | 1578630810 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WITHAM MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAMELOT CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9480 PRIORITY WAY WEST DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462401470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178181240 | ||||||||
FaxNumber: | 3178181022 | ||||||||
Practice Location | |||||||||
Address1: | 1555 COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | LOGANSPORT | ||||||||
State: | IN | ||||||||
PostalCode: | 469471555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5747530404 | ||||||||
FaxNumber: | 5747224638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 06/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRAVERMAN | ||||||||
AuthorizedOfficialFirstName: | KELLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7654858100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | N |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   | 3140N1450X | 06 000466 1 | IN | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
ID | Type | State | Issuer | Description | 100289810 | 05 | IN |   | MEDICAID |