Provider Demographics
NPI:1114127834
Name:DEKALB MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:DEKALB MEMORIAL HOSPITAL, INC
Other - Org Name:DEKALB HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:POLKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-925-4600
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-0623
Mailing Address - Country:US
Mailing Address - Phone:260-927-8105
Mailing Address - Fax:260-333-0664
Practice Address - Street 1:1314 E 7TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2533
Practice Address - Country:US
Practice Address - Phone:260-925-3500
Practice Address - Fax:260-925-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100104110FMedicaid
IN100104110FMedicaid