Healthcare Provider Details

I. General information

NPI: 1255875712
Provider Name (Legal Business Name): DEKALB MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E 7TH ST STE B
AUBURN IN
46706-2534
US

IV. Provider business mailing address

PO BOX 623
AUBURN IN
46706-0623
US

V. Phone/Fax

Practice location:
  • Phone: 260-920-2501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01039551A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23001905A
License Number StateIN

VIII. Authorized Official

Name: CRAIG POLKOW
Title or Position: CEO
Credential:
Phone: 260-920-2501