Healthcare Provider Details

I. General information

NPI: 1578630810
Provider Name (Legal Business Name): WITHAM MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 COMMERCE DR
LOGANSPORT IN
46947-1555
US

IV. Provider business mailing address

9480 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-1470
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-0404
  • Fax: 574-722-4638
Mailing address:
  • Phone: 317-818-1240
  • Fax: 317-818-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number06 000466 1
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100289810
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

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