Basic Information
| Provider Information | |||||||||
| NPI: | 1811168560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HOSPITAL AND HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124825656 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1314 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475012860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124825656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129960507 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200048850U | 05 | IN | MEDICAID |