1790788537 NPI number — SULLIVAN COUNTY COMMUNITY HOSPITAL

Table of content: (NPI 1790788537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788537 NPI number — SULLIVAN COUNTY COMMUNITY HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SULLIVAN COUNTY COMMUNITY 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:
1790788537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
2110 N. HOSPITAL BLVD, SUITE #3
Provider Business Mailing Address City Name:
SULLIVAN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47882-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-268-4311
Provider Business Mailing Address Fax Number:
812-268-2654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 N HOSPITAL BLVD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULLIVAN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47882-7656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-268-4311
Provider Business Practice Location Address Fax Number:
812-268-2654
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
KENISHA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
812-268-4311

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 05-003248-1 , 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: 200387670A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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