Basic Information
| Provider Information | |||||||||
| NPI: | 1699852772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HCMH DIVERSIFIED MANAGEMENT CORP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HCMH DIVERSIFIED PROF LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 653 | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473620653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 FOREST RIDGE PARKWAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473622943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | JANSSEN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7655211508 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 000000097943 | 01 | IN | ANTHEM | OTHER |