MEDICARE: WITHAM 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	314000000X	Skilled Nursing Facility	11-000572-1	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720264591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WITHAM MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	9480 PRIORITY WAY WEST DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1470
Country	:	US
Telephone Number	:	317-818-1240
Fax Number	:	317-818-1022

Provider Business Practice Location Address
First Line	:	3550 CENTRAL AVE
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-2035
Country	:	US
Telephone Number	:	812-379-9669
Fax Number	:	812-378-5248

Authorized Official
Title or Position	:	CEO, PRESIDENT
Name	:	KELLY BRAVERMAN
Credential	:
Telephone Number	:	765-481-8100

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	06/24/2022

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Directions to “WITHAM MEMORIAL HOSPITAL ” Practice Location

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