Provider Demographics
NPI:1881843522
Name:LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC
Entity Type:Organization
Organization Name:LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC
Other - Org Name:FRENCH LICK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-996-0507
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-8478
Mailing Address - Fax:812-996-8497
Practice Address - Street 1:679 S STATE ROAD 145
Practice Address - Street 2:
Practice Address - City:FRENCH LICK
Practice Address - State:IN
Practice Address - Zip Code:47432-8328
Practice Address - Country:US
Practice Address - Phone:812-936-6400
Practice Address - Fax:812-936-6402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE COMPANY OF MARY HOSPITA OF INDIANA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-18
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200048850VMedicaid
IN158507Medicare Oscar/Certification
IN258890Medicare PIN