Provider Demographics
NPI:1326180803
Name:WOODLAWN HOSPITAL
Entity Type:Organization
Organization Name:WOODLAWN HOSPITAL
Other - Org Name:GOLDEN YEARS HOMESTEAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-223-3141
Mailing Address - Street 1:3136 GOEGLEIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6685
Mailing Address - Country:US
Mailing Address - Phone:260-749-9655
Mailing Address - Fax:260-749-9656
Practice Address - Street 1:3136 GOEGLEIN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6685
Practice Address - Country:US
Practice Address - Phone:260-749-9655
Practice Address - Fax:260-749-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000282314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0501560MMedicaid
IN155755Medicare Oscar/Certification