Provider Demographics
NPI:1003821729
Name:HUNTINGTON MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:HUNTINGTON MEMORIAL HOSPITAL, INC.
Other - Org Name:PARKVIEW HUNTINGTON HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-266-9313
Mailing Address - Street 1:PO BOX 5600
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5600
Mailing Address - Country:US
Mailing Address - Phone:260-373-7008
Mailing Address - Fax:260-373-7059
Practice Address - Street 1:2001 STULTS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750
Practice Address - Country:US
Practice Address - Phone:260-355-3304
Practice Address - Fax:260-355-3346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUNTINGTON MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN100268810A282N00000X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1500091Medicaid
OH2414391Medicaid
FL912781000Medicaid
IN000000005189OtherMPLAN IDENTIFICATION #
IN100268810AMedicaid
MI304560283Medicaid
ALPAR0091NMedicaid
AK154510105Medicaid
KY01300367Medicaid
IN000000098130OtherINDIANA COMP. ID#
IN032126100OtherBLACK LUNG ID#
1516840OtherNCPDP
NJ0037648Medicaid
MO016138406Medicaid
IN3072OtherPHP IDENTIFICATION #
IN000000098130OtherANTHEM IDENTIFICATION #
NE10025091500Medicaid
OH2414391Medicaid
ALPAR0091NMedicaid
IN000000005189OtherMPLAN IDENTIFICATION #