Provider Demographics
NPI:1922393768
Name:PERRY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PERRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:13TH STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERWIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-547-0170
Mailing Address - Street 1:8885 STATE ROAD 237
Mailing Address - Street 2:
Mailing Address - City:TELL CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47586-8567
Mailing Address - Country:US
Mailing Address - Phone:812-547-7011
Mailing Address - Fax:
Practice Address - Street 1:148 13TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TELL CITY
Practice Address - State:IN
Practice Address - Zip Code:47586-1937
Practice Address - Country:US
Practice Address - Phone:812-547-3447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034119Medicaid