Healthcare Provider Details

I. General information

NPI: 1932196177
Provider Name (Legal Business Name): PULASKI MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W WASHINGTON CENTER RD
FT WAYNE IN
46825-4155
US

IV. Provider business mailing address

616 E 13TH ST
WINAMAC IN
46996-1117
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-2552
  • Fax: 260-487-9912
Mailing address:
  • Phone: 419-247-2880
  • Fax: 419-247-2872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number05-000522-1
License Number StateIN

VIII. Authorized Official

Name: MR. GREGG MALOTT
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 57494624100