Healthcare Provider Details

I. General information

NPI: 1174768618
Provider Name (Legal Business Name): WITHAM MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 03/26/2022
Certification Date: 03/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CASON ST
LAFAYETTE IN
47904-2613
US

IV. Provider business mailing address

PO BOX 221648
LOUISVILLE KY
40252-1648
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-4102
  • Fax: 765-447-7386
Mailing address:
  • Phone: 502-412-5847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number08-000037-1
License Number StateIN

VIII. Authorized Official

Name: KELLY BRAVERMAN
Title or Position: CEO, PRESIDENT
Credential:
Phone: 765-485-8100