Provider Demographics
NPI:1346263217
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:SIMMONS LOVING CARE HEALTH FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
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 1:700 E 21ST AVE
Mailing Address - Street 2:P.O. BOX 1678
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-2726
Mailing Address - Country:US
Mailing Address - Phone:219-882-2563
Mailing Address - Fax:219-882-2616
Practice Address - Street 1:700 E 21ST AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407
Practice Address - Country:US
Practice Address - Phone:219-882-2563
Practice Address - Fax:219-882-2616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000368-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100275220AMedicaid