Basic Information
| Provider Information | |||||||||
| NPI: | 1689602047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITALS OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY GROUP FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3826 SOLUTIONS CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Practice Location | |||||||||
| Address1: | 10122 E 10TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555717 | ||||||||
| FaxNumber: | 3173553760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | KIRKHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3173554887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITALS OF INDIANA INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5085061 | 01 | IN | AETNA | OTHER | 100236570A | 05 | IN | MEDICAID | CA1777 | 01 | IN | RAILROAD MEDICARE | OTHER |