Basic Information
| Provider Information | |||||||||
| NPI: | 1801810346 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF HOWARD COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY ONCOLOGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654538571 | ||||||||
| FaxNumber: | 7654538637 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654538571 | ||||||||
| FaxNumber: | 7654538637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7654538456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 01067807A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RH0003X | 01056265A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200011260D | 05 | IN | MEDICAID |