WASHINGTON COUNTY MEMORIAL HOSPITAL

Provider Demographics

• NPI: 1124062419
• Name: WASHINGTON COUNTY MEMORIAL HOSPITAL
• Entity type: Organization
• Organization Name: WASHINGTON COUNTY MEMORIAL HOSPITAL
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: JOE
• Authorized Official - Last Name: ROCHE
• Authorized Official - Phone: 8128-863-5881
• Mailing Address - Street 1: 911 N. SHELBY ST.
• Mailing Address - City: SALEM
• Mailing Address - State: IN
• Mailing Address - Zip Code: 47167-2304
• Mailing Address - Country: US
• Mailing Address - Phone: 812-883-5881
• Mailing Address - Fax: 812-883-8557
• Practice Address - Street 1: 911 N. SHELBY ST.
• Practice Address - City: SALEM
• Practice Address - State: IN
• Practice Address - Zip Code: 47167-2304
• Practice Address - Country: US
• Practice Address - Phone: 812-883-5881
• Practice Address - Fax: 812-883-8557
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-16
• Last Update Date: 2009-07-22

Provider Licenses

State	License ID	Taxonomies
		207L00000X, 207P00000X, 207Q00000X, 207V00000X, 207X00000X, 2085R0202X, 208VP0000X, 275N00000X, 3416L0300X, 363L00000X
IN	0050871	282NC0060X
IN	07-005087-1	282NC0060X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	282NC0060X	Hospitals	General Acute Care Hospital	Critical Access
No	207L00000X	Allopathic & Osteopathic Physicians	Anesthesiology		Group - Multi-Specialty
No	207P00000X	Allopathic & Osteopathic Physicians	Emergency Medicine		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	207V00000X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology		Group - Multi-Specialty
No	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	2085R0202X	Allopathic & Osteopathic Physicians	Radiology	Diagnostic Radiology	Group - Multi-Specialty
No	208VP0000X	Allopathic & Osteopathic Physicians	Pain Medicine	Pain Medicine	Group - Multi-Specialty
No	275N00000X	Hospital Units	Medicare Defined Swing Bed Unit
No	3416L0300X	Transportation Services	Ambulance	Land Transport
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	200009980A	Medicaid
IN	200009980E	Medicaid
IN	000000054337	Other	BLUE CROSS PROVIDER #
IN	100269720	Medicaid
IN	200009980D	Medicaid
IN	200009980G	Medicaid
IN	200009980B	Medicaid
IN	030969400	Other	FEDERAL BLACK LUNG
IN	100269720A	Medicaid
IN	200009980C	Medicaid
IN	200009980F	Medicaid
IN	940950	Other	MEDICARE PART B
IN	100367960A	Medicaid
IN	030969400	Other	FEDERAL BLACK LUNG
IN	100269720	Medicaid
IN	200009980C	Medicaid
IN	200009980D	Medicaid