Basic Information
| Provider Information | |||||||||
| NPI: | 1679756753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLINTON GARDENS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478421053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177882500 | ||||||||
| FaxNumber: | 3177882509 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658322491 | ||||||||
| FaxNumber: | 7658322685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2007 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN CAMP | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO OF ASC | ||||||||
| AuthorizedOfficialTelephone: | 3177882500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 07-000212-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100285040D | 05 | IN | MEDICAID |