Basic Information
| Provider Information | |||||||||
| NPI: | 1699757401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WITHAM MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 N LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2605 N LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858000 | ||||||||
| FaxNumber: | 7654858118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | POGAS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7654858100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100469040A | 05 | IN | MEDICAID | 201032590A | 05 | IN | MEDICAID | 100269130A | 05 | IN | MEDICAID |