Provider Demographics
NPI:1114254190
Name:WOODLAWN HOSPITAL
Entity Type:Organization
Organization Name:WOODLAWN HOSPITAL
Other - Org Name:FULTON COUNTY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-224-1118
Mailing Address - Street 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-233-3141
Mailing Address - Fax:574-223-5847
Practice Address - Street 1:100 E DUNN STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IN
Practice Address - Zip Code:49631
Practice Address - Country:US
Practice Address - Phone:574-857-5995
Practice Address - Fax:574-223-5847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODLAWN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-11
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
IN71002042A363L00000X
IN01045175A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100269770DMedicaid
IN200855890Medicaid
IN200384260Medicaid
INQ74059Medicare UPIN
IN200384260Medicaid
ING38613Medicare UPIN