Provider Demographics
NPI:1689770083
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:PETERSBURG FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-996-0507
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-8478
Mailing Address - Fax:
Practice Address - Street 1:1003 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567
Practice Address - Country:US
Practice Address - Phone:812-354-3458
Practice Address - Fax:812-354-3459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE COMPANY OF MARY HOSPITAL OF INDIANA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-15
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200048850KMedicaid
INCB3118OtherMEDICARE RAILROAD
IN153872Medicare Oscar/Certification