Basic Information
| Provider Information | |||||||||
| NPI: | 1861420689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HOSPITAL AND HEALTH CARE CENTER PSYCHIATRIC PHYSICIAN PRACTIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124818493 | ||||||||
| FaxNumber: | 8124818497 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 W 13TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475461855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124815780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124822345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | CB3118 | 01 | IN | RAILROAD MEDICARE | OTHER |