Basic Information
| Provider Information | |||||||||
| NPI: | 1598088064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HOSPITAL AND HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129968476 | ||||||||
| FaxNumber: | 8129968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 W 13TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475461855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129967388 | ||||||||
| FaxNumber: | 8129960150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129962345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 200048850Y | 05 | IN | MEDICAID |