Provider Demographics
NPI:1770871410
Name:WITHAM MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-485-8100
Mailing Address - Street 1:PO BOX 221648
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-1648
Mailing Address - Country:US
Mailing Address - Phone:502-412-5847
Mailing Address - Fax:
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IN
Practice Address - Zip Code:47330-9676
Practice Address - Country:US
Practice Address - Phone:765-855-3424
Practice Address - Fax:765-485-1087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WITHAM MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-15
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-000456-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100288750Medicaid
IN100288750BMedicaid