Provider Demographics
NPI:1720026180
Name:PUTNAM COUNTY HOSPITAL
Entity Type:Organization
Organization Name:PUTNAM COUNTY HOSPITAL
Other - Org Name:THE WATERS OF MARTINSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
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 1:2055 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-3158
Mailing Address - Country:US
Mailing Address - Phone:765-342-3305
Mailing Address - Fax:765-342-9575
Practice Address - Street 1:2055 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-3158
Practice Address - Country:US
Practice Address - Phone:765-342-3305
Practice Address - Fax:765-342-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000096-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000476412OtherATNEHM OT
IN100290890CMedicaid
IN000000381423OtherANTHEM BCBS
IN000000476411OtherANTHEM PT
IN000000476413OtherANTHEM ST
IN000000476412OtherATNEHM OT
IN155183Medicare Oscar/Certification