Provider Demographics
NPI:1861511370
Name:STATE OF INDIANA, AUDITOR OF STATE
Entity Type:Organization
Organization Name:STATE OF INDIANA, AUDITOR OF STATE
Other - Org Name:LOGANSPORT STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-737-3611
Mailing Address - Street 1:1098 S STATE ROAD 25
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-6723
Mailing Address - Country:US
Mailing Address - Phone:574-722-4141
Mailing Address - Fax:574-735-3414
Practice Address - Street 1:1098 S STATE ROAD 25
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-6723
Practice Address - Country:US
Practice Address - Phone:574-722-4141
Practice Address - Fax:574-735-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN283Q00000X, 315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered283Q00000XHospitalsPsychiatric Hospital
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941780Medicare ID - Type UnspecifiedMEDICARE B