Provider Demographics
NPI:1154321099
Name:JOHNSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHNSON MEMORIAL HOSPITAL
Other - Org Name:JOHNSON MEMORIAL HOSPITAL HEALTH AFFILIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR,REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LARREL
Authorized Official - Middle Name:I
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-736-3588
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-0800
Mailing Address - Country:US
Mailing Address - Phone:317-738-7878
Mailing Address - Fax:317-738-7872
Practice Address - Street 1:1155 W JEFFERSON ST
Practice Address - Street 2:STE 202
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2732
Practice Address - Country:US
Practice Address - Phone:317-738-7878
Practice Address - Fax:317-738-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN005001207R00000X, 207RP1001X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200390880AMedicaid
IN000000264062OtherANTHEM PROVIDER NUMBER
IN198160Medicare Oscar/Certification
IN=========OtherTAX ID NUMBER