1215928536 NPI number — PERRY COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1215928536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215928536 NPI number — PERRY COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERRY 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:
PERRY COUNTY FAMILY PRACTICE
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:
1215928536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8885 STATE ROAD 237
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TELL CITY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47586-8567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-547-7011
Provider Business Mailing Address Fax Number:
812-547-9543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18485 STATE RD 37
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEOPOLD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47551-8072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-843-3038
Provider Business Practice Location Address Fax Number:
812-843-3084
Provider Enumeration Date:
11/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HERWIG
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
812-547-0170

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 65944290 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15D1043196 . This is a "CLIA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000371434 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200531240A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78904927 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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