Provider Demographics
NPI:1760472252
Name:HENRY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HENRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:BETHANY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO OF ASC
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:317-788-2500
Mailing Address - Street 1:3518 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-3226
Mailing Address - Country:US
Mailing Address - Phone:317-783-4042
Mailing Address - Fax:317-781-3044
Practice Address - Street 1:3518 S SHELBY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-3226
Practice Address - Country:US
Practice Address - Phone:317-783-4042
Practice Address - Fax:317-781-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10-000142-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100266940BMedicaid
IN155237Medicare Oscar/Certification