Basic Information
| Provider Information | |||||||||
| NPI: | 1922196229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745837111 | ||||||||
| FaxNumber: | 5745831703 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745837111 | ||||||||
| FaxNumber: | 5745831703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5745837111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 60004820A | IN | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 000000097136 | 01 | IN | BLUE CROSS DME | OTHER | 201026750A | 05 | IN | MEDICAID |