Provider Demographics
NPI:1508845397
Name:LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC
Entity Type:Organization
Organization Name:LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC
Other - Org Name:MEMORIAL HOSPITAL & HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-482-2345
Mailing Address - Street 1:800 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2514
Mailing Address - Country:US
Mailing Address - Phone:812-482-2345
Mailing Address - Fax:812-482-0214
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-482-2345
Practice Address - Fax:812-482-0214
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF LITTLE COMPANY OF MARY OF INDIANA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-11
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050051021314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100284870AMedicaid
INBLACK LUNGOther301557
IN000000097731OtherBLUE CROSS SKILLED NSG
IN=========OtherCOMMERCIAL SKILLED NSG
IN100284870AMedicaid