Basic Information
| Provider Information | |||||||||
| NPI: | 1720026180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUTNAM COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE WATERS OF MARTINSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 HERITAGE DR | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461513158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653423305 | ||||||||
| FaxNumber: | 7653429575 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 HERITAGE DR | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461513158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653423305 | ||||||||
| FaxNumber: | 7653429575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEATHERFORD | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7656552620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05-000096-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000476412 | 01 | IN | ATNEHM OT | OTHER | 100290890C | 05 | IN | MEDICAID | 000000381423 | 01 | IN | ANTHEM BCBS | OTHER | 000000476411 | 01 | IN | ANTHEM PT | OTHER | 000000476413 | 01 | IN | ANTHEM ST | OTHER |