Provider Demographics
NPI:1740403419
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:MALOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-946-2100
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-0279
Mailing Address - Country:US
Mailing Address - Phone:574-946-2100
Mailing Address - Fax:574-946-2107
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1173
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:574-946-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
IN261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270360AMedicaid
IN201272330AMedicaid
IN201272330AMedicaid