Healthcare Provider Details

I. General information

NPI: 1346867942
Provider Name (Legal Business Name): HENRY COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 NATIONAL RD W
RICHMOND IN
47374-4745
US

IV. Provider business mailing address

PO BOX 485
NEW CASTLE IN
47362-0485
US

V. Phone/Fax

Practice location:
  • Phone: 765-965-6679
  • Fax:
Mailing address:
  • Phone: 765-521-1516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARISSA FULLER
Title or Position: CREDENTIALING COORDINATOR
Credential: CPC
Phone: 765-599-3534