Basic Information
| Provider Information | |||||||||
| NPI: | 1194725796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SELECT SPECIALTY HOSPITAL - NORTHWEST INDIANA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG RD | ||||||||
| Address2: | LEGAL DEPT. | ||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463251931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198522409 | ||||||||
| FaxNumber: | 2199332298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 008899 | IN | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 200110710A | 05 | IN | MEDICAID | 000000112474 | 01 | IN | BCBS IN | OTHER |