Basic Information
| Provider Information | |||||||||
| NPI: | 1770562159 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDINAL HEALTH SYSTEMS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BALL MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657411592 | ||||||||
| FaxNumber: | 7657473841 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657411592 | ||||||||
| FaxNumber: | 7657473841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GILDERSLEEVE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVEVP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7657473365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 1542 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 000000295080 | 01 | IN | BALL MEMORIAL DIALYSIS UN | OTHER |