Provider Demographics
NPI:1710012505
Name:RENAISSANCE SPECIALTY HOSPITAL OF CENTRAL INDIANA OPERATIONS CO., LLC
Entity Type:Organization
Organization Name:RENAISSANCE SPECIALTY HOSPITAL OF CENTRAL INDIANA OPERATIONS CO., LLC
Other - Org Name:INTEGRA SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WESP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-282-5822
Mailing Address - Street 1:2401 W UNIVERSITY AVE
Mailing Address - Street 2:8TH FLOOR NORTH TOWER
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3428
Mailing Address - Country:US
Mailing Address - Phone:765-282-5822
Mailing Address - Fax:765-289-5170
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:8TH FLOOR NORTH TOWER
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-282-5822
Practice Address - Fax:765-289-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 363L00000X, 363LA2100X
IN060042861282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282E00000XHospitalsLong Term Care HospitalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200509740Medicaid
IN200509740Medicaid
IN152025Medicare ID - Type Unspecified