Provider Demographics
NPI:1104855980
Name:HENRY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HENRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:HICKORY CREEK AT MADISON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-521-1515
Mailing Address - Street 1:1945 CRAGMONT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2257
Mailing Address - Country:US
Mailing Address - Phone:812-273-4696
Mailing Address - Fax:812-273-6263
Practice Address - Street 1:1945 CRAGMONT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2257
Practice Address - Country:US
Practice Address - Phone:812-273-4696
Practice Address - Fax:812-273-6263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000348-2314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100288390Medicaid
IN100288390Medicaid