Provider Demographics
NPI:1972584795
Name:PERRY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PERRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:TROY 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 1:109 US HIGHWAY 66 E
Mailing Address - Street 2:
Mailing Address - City:TELL CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47586-2755
Mailing Address - Country:US
Mailing Address - Phone:812-547-9549
Mailing Address - Fax:812-547-9543
Practice Address - Street 1:315 MAIN ST.
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IN
Practice Address - Zip Code:47588
Practice Address - Country:US
Practice Address - Phone:812-547-9552
Practice Address - Fax:812-547-9553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERRY COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-09
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200531550AMedicaid
IN000000374718OtherANTHEM
KY65944423Medicaid
KY78904778Medicaid
IN15D1043329OtherCLIA
KY78904778Medicaid