Provider Demographics
NPI:1629066790
Name:WITHAM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:MCGIVNEY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, PRESIDENT
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:765-485-8100
Mailing Address - Street 1:6401 S US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4749
Mailing Address - Country:US
Mailing Address - Phone:812-298-3002
Mailing Address - Fax:812-298-3044
Practice Address - Street 1:2907 E 136TH ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9402
Practice Address - Country:US
Practice Address - Phone:317-846-0265
Practice Address - Fax:317-846-3944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN04-000545-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267350Medicaid