MEDICARE: ADAMS COUNTY MEMORIAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	050002831	IN
2	310400000X	Assisted Living Facility
3	314000000X	Skilled Nursing Facility	050002831	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0220	OTHER	RCAP

General Provider Information

NPI Number	:	1073554200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADAMS COUNTY MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	1100 MERCER AVE
Second Line	:
City	:	DECATUR
State	:	IN
Zip	:	46733-2303
Country	:	US
Telephone Number	:	260-724-2145
Fax Number	:	260-728-3852

Provider Business Practice Location Address
First Line	:	6701 SOUTH ANTHONY BOULEVARD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2035
Country	:	US
Telephone Number	:	260-447-0800
Fax Number	:	260-447-7369

Authorized Official
Title or Position	:	CFO/TREASURER
Name	:	MR. DANE WHEELER
Credential	:	CPA
Telephone Number	:	260-724-2145

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	09/29/2014

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Directions to “ADAMS COUNTY MEMORIAL HOSPITAL ” Practice Location

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