Provider Demographics
NPI:1144388505
Name:DAVIESS COUNTY HOSPITAL
Entity Type:Organization
Organization Name:DAVIESS COUNTY HOSPITAL
Other - Org Name:PETERSBURG MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MEMEBER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-254-8620
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47567-1247
Mailing Address - Country:US
Mailing Address - Phone:812-354-8426
Mailing Address - Fax:812-354-9134
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-1247
Practice Address - Country:US
Practice Address - Phone:812-354-8426
Practice Address - Fax:812-354-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028253A261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200042020AMedicaid
IN200042020AMedicaid
INCA5604Medicare PIN
INCG3197Medicare PIN