Provider Demographics
NPI:1598826752
Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ABDELRAHMAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ABDALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-883-5881
Mailing Address - Street 1:125 SPRING MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-9429
Mailing Address - Country:US
Mailing Address - Phone:812-883-3963
Mailing Address - Fax:
Practice Address - Street 1:125 SPRING MEADOW CIR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-9429
Practice Address - Country:US
Practice Address - Phone:812-883-3963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058910A247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000342198OtherBLUE CROSS BLUE SHIELDS
IN01058910AOtherSTATE LICENSE
IN203299OtherCOMMERCIAL ID
IN01058910AOtherSTATE LICENSE
IN=========OtherAMA
IN940950GGMedicare ID - Type Unspecified