Provider Demographics
NPI:1114986924
Name:PUTNAM COUNTY HOSPITAL
Entity Type:Organization
Organization Name:PUTNAM COUNTY HOSPITAL
Other - Org Name:PROVIDENCE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEATHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-655-2620
Mailing Address - Street 1:P.O. BOX 97
Mailing Address - Street 2:
Mailing Address - City:ST. MARY OF THE WOODS
Mailing Address - State:IN
Mailing Address - Zip Code:47876-1095
Mailing Address - Country:US
Mailing Address - Phone:812-535-1051
Mailing Address - Fax:812-535-1005
Practice Address - Street 1:1 SISTERS OF PROVIDENCE
Practice Address - Street 2:PROVIDENCE HEALTH CARE CENTER
Practice Address - City:ST. MARY WOODS
Practice Address - State:IN
Practice Address - Zip Code:47876-1095
Practice Address - Country:US
Practice Address - Phone:812-535-1051
Practice Address - Fax:812-535-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155802OtherCCN
IN200429840AMedicaid