1346292737 NPI number — DECATUR COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1346292737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346292737 NPI number — DECATUR COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DECATUR 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:
SOUTH SHORE HEALTH & REHABILITATION 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:
1346292737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
353 TYLER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46402-1149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-886-7070
Provider Business Mailing Address Fax Number:
219-886-0810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 TYLER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46402-1149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-886-7070
Provider Business Practice Location Address Fax Number:
219-886-0810
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALOTT
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
574-946-2103

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  14-000369-1 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100275190B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100275190 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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