Provider Demographics
NPI:1033132477
Name:JOHNSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHNSON MEMORIAL HOSPITAL
Other - Org Name:THE WATERS OF FORT WAYNE SKILLED NURSING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-736-3396
Mailing Address - Street 1:1125 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2140
Mailing Address - Country:US
Mailing Address - Phone:317-736-7549
Mailing Address - Fax:317-736-2692
Practice Address - Street 1:5544 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7475
Practice Address - Country:US
Practice Address - Phone:260-749-9506
Practice Address - Fax:260-493-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000214-2314000000X
332BN1400X
IN332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267240AMedicaid
IN100267240AMedicaid
IN0435080007Medicare NSC