Basic Information
| Provider Information | |||||||||
| NPI: | 1578636783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HCMH LIFELINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1000 NORTH 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 NORTH 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RING | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7655211515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 060050282 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Personal Emergency Response Attendant |
ID Information
| ID | Type | State | Issuer | Description | 200187860A | 05 | IN | MEDICAID |