Basic Information
| Provider Information | |||||||||
| NPI: | 1356476154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADAMS COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADAMS WOODCREST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
| FaxNumber: | 2607283867 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
| FaxNumber: | 2607283867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2607242145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 070005562 | IN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 313M00000X | 070005562 | IN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 100290130A | 05 | IN | MEDICAID |