Basic Information
| Provider Information | |||||||||
| NPI: | 1700256948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SULLIVAN COUNTY COMMUNITY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 230 | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478820230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122682650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 N HOSPITAL BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122682650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | WATSON | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8122684311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 201246990F | 05 | IN | MEDICAID |