Basic Information
| Provider Information | |||||||||
| NPI: | 1972516110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129968476 | ||||||||
| FaxNumber: | 8129968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475462609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129960400 | ||||||||
| FaxNumber: | 8129960653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 8129962345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01062502A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200048850O | 05 | IN | MEDICAID | CB3118 | 01 | IN | RAILROAD MEDICARE | OTHER |