Provider Demographics
NPI:1598192957
Name:WITHAM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:BROOKE KNOLL VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-485-8067
Mailing Address - Street 1:8455 KEYSTONE CROSSING
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-4353
Mailing Address - Country:US
Mailing Address - Phone:317-818-1240
Mailing Address - Fax:317-552-2086
Practice Address - Street 1:1108 KINGWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-5500
Practice Address - Country:US
Practice Address - Phone:317-204-1100
Practice Address - Fax:317-271-7054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WITHAM MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-01
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13-012901-1314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300023505Medicaid