Basic Information
| Provider Information | |||||||||
| NPI: | 1902897937 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEKALB MEMORIAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKVIEW DEKALB HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10501 CORPORATE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604377558 | ||||||||
| FaxNumber: | 2609254733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609254600 | ||||||||
| FaxNumber: | 2609254733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EICHER | ||||||||
| AuthorizedOfficialFirstName: | NATASHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2609202500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 01039551A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 231H00000X | 23002422A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 3336I0012X | 60000349A | IN | N | Suppliers | Pharmacy | Institutional Pharmacy | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 282N00000X | 10-005041-1 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000000097746 | 01 | IN | BLUE CROSS | OTHER | 100269460A | 05 | IN | MEDICAID | 1562518 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 100287120A | 05 | IN | MEDICAID |