Provider Demographics
NPI:1881816148
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:BROOKSIDE CARE STRATEGIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
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 1:402 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-3115
Mailing Address - Country:US
Mailing Address - Phone:574-200-9706
Mailing Address - Fax:
Practice Address - Street 1:505 NORTH GAVIN STREET
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-289-1915
Practice Address - Fax:765-289-6435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07-000311-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100285520Medicaid