Provider Demographics
NPI:1205844495
Name:WHITLEY MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:WHITLEY MEMORIAL HOSPITAL, INC.
Other - Org Name:PARKVIEW WHITLEY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP -- CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-266-9313
Mailing Address - Street 1:PO BOX 5600
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5600
Mailing Address - Country:US
Mailing Address - Phone:260-373-7008
Mailing Address - Fax:260-373-7059
Practice Address - Street 1:1260 E STATE ROAD 205
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725
Practice Address - Country:US
Practice Address - Phone:260-248-9302
Practice Address - Fax:260-248-9107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITLEY MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005090-1282N00000X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000098126OtherINDIANA COMP. ID#
OH9422664Medicaid
IN4744OtherPHP IDENTIFICATION #
IN03697300OtherBLACK LUNG ID#
1509946OtherNCPDP
IN100268830AMedicaid
MI304608369Medicaid
IN000000004969OtherMPLAN IDENTIFICATION #
KY01300664Medicaid
IN351965665-001OtherCHAMPUS IDENTIFICATION #
IN000000098126OtherANTHEM IDENTIFICATION #
MI404608378Medicaid
IN000000098126OtherANTHEM IDENTIFICATION #
OH9422664Medicaid
IN000000098126OtherANTHEM IDENTIFICATION #