Provider Demographics
NPI:1831679620
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:PULASKI MEMORIAL HOSPITAL NORTH JUDSON FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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:574-946-2103
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:
Practice Address - Street 1:414 LANE ST
Practice Address - Street 2:
Practice Address - City:NORTH JUDSON
Practice Address - State:IN
Practice Address - Zip Code:46366-1226
Practice Address - Country:US
Practice Address - Phone:574-896-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PULASKI MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-21
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014361Medicaid