Provider Demographics
NPI:1619318185
Name:PUTNAM COUNTY HOSPITAL
Entity Type:Organization
Organization Name:PUTNAM COUNTY HOSPITAL
Other - Org Name:WELLBROOKE OF AVON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEATHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-655-2620
Mailing Address - Street 1:PO BOX 221648
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-1648
Mailing Address - Country:US
Mailing Address - Phone:502-412-5847
Mailing Address - Fax:
Practice Address - Street 1:10307 E COUNTY ROAD 100 N
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-1250
Practice Address - Country:US
Practice Address - Phone:317-273-2144
Practice Address - Fax:515-875-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN013085314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201279600AMedicaid
IN155811Medicare Oscar/Certification