Basic Information
| Provider Information | |||||||||
| NPI: | 1881843522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FRENCH LICK FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129968478 | ||||||||
| FaxNumber: | 8129968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 679 S STATE ROAD 145 | ||||||||
| Address2: | |||||||||
| City: | FRENCH LICK | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474328328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129366400 | ||||||||
| FaxNumber: | 8129366402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2008 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129960507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITA OF INDIANA INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 200048850V | 05 | IN | MEDICAID |