Provider Demographics
NPI:1508047630
Name:INDIANA REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:INDIANA REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONGAWARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-357-7008
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:835 HOSPITAL ROAD
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-0788
Mailing Address - Country:US
Mailing Address - Phone:724-357-7008
Mailing Address - Fax:724-357-7414
Practice Address - Street 1:1265 WAYNE AVE BLDG SUITE201
Practice Address - Street 2:CENTER FOR WOUND HEALING
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3501
Practice Address - Country:US
Practice Address - Phone:724-357-7008
Practice Address - Fax:724-357-7414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
PA090701282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000068OtherHIGHMARK
PA1007713530032Medicaid
PA39-0173Medicare PIN