Provider Demographics
NPI:1336548353
Name:PULASKI MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:MAJESTIC CARE OF WEST ALLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-946-2100
Mailing Address - Street 1:6050 S CR 800 E-92
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9201
Mailing Address - Country:US
Mailing Address - Phone:260-625-3545
Mailing Address - Fax:260-625-4993
Practice Address - Street 1:6050 S CR 800 E-92
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9201
Practice Address - Country:US
Practice Address - Phone:260-625-3545
Practice Address - Fax:260-625-4993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14-000215-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
155322Medicare Oscar/Certification