Provider Demographics
NPI:1043317415
Name:ELKHART GENERAL HOSPITAL INC
Entity Type:Organization
Organization Name:ELKHART GENERAL HOSPITAL INC
Other - Org Name:NEW DIRECTIONS WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:574-523-7914
Mailing Address - Street 1:PO BOX 660376
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-0001
Mailing Address - Country:US
Mailing Address - Phone:574-523-3148
Mailing Address - Fax:574-523-3492
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-2750
Practice Address - Fax:574-389-4875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART GENERAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005017-1261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200450070AMedicaid
IN261650Medicare PIN
IN200450070AMedicaid