Provider Demographics
NPI:1932315264
Name:WOODLAWN HOSPITAL
Entity Type:Organization
Organization Name:WOODLAWN HOSPITAL
Other - Org Name:WOODLAWN MEDICAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-224-1118
Mailing Address - Street 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-223-3141
Mailing Address - Fax:574-223-5847
Practice Address - Street 1:1400 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-8931
Practice Address - Country:US
Practice Address - Phone:574-223-3141
Practice Address - Fax:574-223-5847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODLAWN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046904207Q00000X
IN01031969207Q00000X
IN01051336207Q00000X
IN01038921207Q00000X
IN01044502207Q00000X
IN01049343208000000X
IN01042718208000000X
IN71000786363LF0000X
IN71000682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100269770AMedicaid
H15866Medicare UPIN
H31557Medicare UPIN
E73944Medicare UPIN
G77178Medicare UPIN
270990Medicare ID - Type Unspecified
233730Medicare ID - Type Unspecified
194980Medicare ID - Type Unspecified
P12382Medicare UPIN
G03604Medicare UPIN
P12372Medicare UPIN