Healthcare Provider Details

I. General information

NPI: 1720264591
Provider Name (Legal Business Name): WITHAM MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 CENTRAL AVE
COLUMBUS IN
47203-2035
US

IV. Provider business mailing address

9480 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-1470
US

V. Phone/Fax

Practice location:
  • Phone: 812-379-9669
  • Fax: 812-378-5248
Mailing address:
  • Phone: 317-818-1240
  • Fax: 317-818-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11-000572-1
License Number StateIN

VIII. Authorized Official

Name: KELLY BRAVERMAN
Title or Position: CEO, PRESIDENT
Credential:
Phone: 765-481-8100