1255875712 NPI number — DEKALB MEMORIAL HOSPITAL INC

Table of content: (NPI 1255875712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255875712 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:
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:
1255875712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2016
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:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 E 7TH ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-920-2501
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/16/2016

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:
260-920-2501

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  01039551A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , with the licence number: 23001905A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 191560 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com