=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477597631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HOSPITAL OF BREMEN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 01/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 HIGH RD
-----------------------------------------------------
City | BREMEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46506-1093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-546-2211
-----------------------------------------------------
Fax | 574-546-4312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 HIGH RD
-----------------------------------------------------
City | BREMEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46506-1093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-546-2211
-----------------------------------------------------
Fax | 574-546-4312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. DAVID BAILEY
-----------------------------------------------------
Credential | FACHE
-----------------------------------------------------
Telephone | 574-546-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 275N00000X
-----------------------------------------------------
Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
-----------------------------------------------------
License Number | 140050971
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 275N00000X
-----------------------------------------------------
Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
-----------------------------------------------------
License Number | 05-005097-2
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------