Provider Demographics
NPI:1811196843
Name:WITHAM MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:PERSIMMON RIDGE REHABILITATION CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-485-8100
Mailing Address - Street 1:9480 PRIORITY WAY WEST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1470
Mailing Address - Country:US
Mailing Address - Phone:317-818-1240
Mailing Address - Fax:317-818-1022
Practice Address - Street 1:200 N PARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1249
Practice Address - Country:US
Practice Address - Phone:260-726-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-000148-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100275500Medicaid
IN100275500BMedicaid