Basic Information
Provider Information | |||||||||
NPI: | 1902920069 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WITHAM MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOODLAND HILLS CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9480 PRIORITY WAY WEST DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462401470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178181240 | ||||||||
FaxNumber: | 3178181022 | ||||||||
Practice Location | |||||||||
Address1: | 403 BIELBY RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 47025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8125371132 | ||||||||
FaxNumber: | 8125374636 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 10/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INGHAM | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
AuthorizedOfficialTelephone: | 7654858100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 11-000022-1 | IN | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 100274510B | 05 | IN |   | MEDICAID |