MEDICARE: JOHNSON MEMORIAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BN1400X	Nursing Facility Supplies (DME)
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)		IN
3	314000000X	Skilled Nursing Facility	05-000214-2	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033132477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	1125 W JEFFERSON ST
Second Line	:
City	:	FRANKLIN
State	:	IN
Zip	:	46131-2140
Country	:	US
Telephone Number	:	317-736-7549
Fax Number	:	317-736-2692

Provider Business Practice Location Address
First Line	:	5544 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7475
Country	:	US
Telephone Number	:	260-749-9506
Fax Number	:	260-493-1524

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DAVID DUNKLE
Credential	:	MD
Telephone Number	:	317-736-3396

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/30/2023

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