1245399500 NPI number — WITHAM MEMORIAL HOSPITAL

Table of content: (NPI 1245399500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245399500 NPI number — WITHAM MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WITHAM MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALEXANDRIA CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245399500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9480 PRIORITY WAY WEST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46240-1470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-818-1240
Provider Business Mailing Address Fax Number:
317-818-1022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1912 S PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46001-8193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-724-4478
Provider Business Practice Location Address Fax Number:
765-724-7431
Provider Enumeration Date:
12/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRAVERMAN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO, PRESIDENT
Authorized Official Telephone Number:
765-485-8100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  060005181 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100266670 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".