1871972869 NPI number — DEKALB MEMORIAL HOSPITAL, INC

Table of content: (NPI 1871972869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871972869 NPI number — DEKALB MEMORIAL HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB MEMORIAL HOSPITAL, INC
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:
DEKALB HEALTH MEDICAL GROUP
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:
1871972869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 623
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46706-0623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-927-8105
Provider Business Mailing Address Fax Number:
260-333-0664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 E 7TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-927-1982
Provider Business Practice Location Address Fax Number:
260-927-8380
Provider Enumeration Date:
05/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
POLKOW
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
260-925-4600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100104110N , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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