Basic Information
| Provider Information | |||||||||
| NPI: | 1699713339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FMH URGENT CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 RELIABLE PARKWAY | ||||||||
| Address2: | FLOYD MEMORIAL HOSPITAL AND HEALTH SVCS FMH URGENT CARE | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129495482 | ||||||||
| FaxNumber: | 8129495966 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HIGHLANDER POINT STE 103 | ||||||||
| Address2: | FLOYD MEMORIAL HOSPITAL AND HEALTH SVCS FMH URGENT CARE | ||||||||
| City: | FLOYDS KNOBS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471199465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129236336 | ||||||||
| FaxNumber: | 8129230144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8129495500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 100380790A | 05 | IN | MEDICAID |