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General NPI Number Information
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NPI Number | 1174768618
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Entity Type | Organization
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Legal Business Name | WITHAM MEMORIAL HOSPITAL
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Dates
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Enumeration Date | 12/12/2008
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Last Update Date | 03/26/2022
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Provider Practice Location Address
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Address Line | 2201 CASON ST
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City | LAFAYETTE
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State | IN
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Zip | 47904-2613
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Country | US
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Telephone | 765-447-4102
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Fax | 765-447-7386
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Provider Business Mailing Address
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Address Line | PO BOX 221648
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City | LOUISVILLE
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State | KY
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Zip | 40252-1648
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Country | US
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Telephone | 502-412-5847
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Fax |
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Authorized Official
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Title or Position | CEO, PRESIDENT
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Name | KELLY BRAVERMAN
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Credential |
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Telephone | 765-485-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 08-000037-1
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License Number State | IN
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