1093715468 NPI number — ADAMS COUNTY MEMORIAL HOSPITAL

Table of content: TRACIA JACKSON (NPI 1679089031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093715468 NPI number — ADAMS COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADAMS COUNTY 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:
Provider Other Organization Name Type Code:
6
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:
1093715468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 MERCER AVENUE
Provider Second Line Business Mailing Address:
PO BOX 151
Provider Business Mailing Address City Name:
DECATAR
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46733-2303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-724-2145
Provider Business Mailing Address Fax Number:
574-722-3894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 PARKVIEW STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46563-1152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-936-9943
Provider Business Practice Location Address Fax Number:
574-936-4310
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SPRUNGER
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT TREASURER
Authorized Official Telephone Number:
260-724-2145

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  05-000030-1 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 05-000030-1 , 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: 100275260A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100275260 . This is a "AARP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000097805 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100275260 . This is a "ALTERNATE MEDICAID #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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