Provider Demographics
NPI:1790788537
Name:SULLIVAN COUNTY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:SULLIVAN COUNTY COMMUNITY HOSPITAL
Other - Org Name:SULLIVAN COUNTY COMMUNITY HOSPITAL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KENISHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:812-268-4311
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:2110 N. HOSPITAL BLVD, SUITE #3
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0010
Mailing Address - Country:US
Mailing Address - Phone:812-268-4311
Mailing Address - Fax:812-268-2654
Practice Address - Street 1:2110 N HOSPITAL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7656
Practice Address - Country:US
Practice Address - Phone:812-268-4311
Practice Address - Fax:812-268-2654
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SULLIVAN COUNTY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-003248-1251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200387670AMedicaid
IN=========-011OtherANTHEM BLUE CROSS
IN200387670AMedicaid
IN157542Medicare Oscar/Certification