Basic Information
| Provider Information | |||||||||
| NPI: | 1639174204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELBY COUNTY MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILSON MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453652401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374982311 | ||||||||
| FaxNumber: | 9374985527 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453652401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374982311 | ||||||||
| FaxNumber: | 9374985527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COVAULT | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 9374985402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 93701 | OH | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0258993 | 05 | OH | MEDICAID | 9548609 | 05 | OH | MEDICAID |