Provider Demographics
NPI:1083781330
Name:WITHAM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:LIBERTY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:INGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:765-485-8100
Mailing Address - Street 1:9455 DELEGATES ROW
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3805
Mailing Address - Country:US
Mailing Address - Phone:317-818-1240
Mailing Address - Fax:317-818-1022
Practice Address - Street 1:4600 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-4467
Practice Address - Country:US
Practice Address - Phone:765-282-1416
Practice Address - Fax:765-289-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-111269-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267720BMedicaid
IN155400AMedicare ID - Type Unspecified