Provider Demographics
NPI:1326082009
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:MANORCARE HEALTH SERVICES - PRESTWICK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-946-2100
Mailing Address - Street 1:445 S COUNTY ROAD 525 E
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8361
Mailing Address - Country:US
Mailing Address - Phone:317-745-2522
Mailing Address - Fax:317-745-2991
Practice Address - Street 1:445 S COUNTY ROAD 525 E
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8361
Practice Address - Country:US
Practice Address - Phone:317-745-2522
Practice Address - Fax:317-745-2991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000231-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267900Medicaid
IN100267900Medicaid