Healthcare Provider Details

I. General information

NPI: 1962425306
Provider Name (Legal Business Name): JOHNSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N WASHINGTON ST
WAKARUSA IN
46573-9590
US

IV. Provider business mailing address

1125 W JEFFERSON ST
FRANKLIN IN
46131-2140
US

V. Phone/Fax

Practice location:
  • Phone: 574-862-4511
  • Fax: 574-862-4005
Mailing address:
  • Phone: 317-736-7549
  • Fax: 317-736-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number06-000521-1
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateIN

VIII. Authorized Official

Name: DAVID DUNKLE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 317-736-3396