Provider Demographics
NPI:1841544632
Name:PULASKI MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:PULASKI MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:MALOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-946-2103
Mailing Address - Street 1:616 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1117
Mailing Address - Country:US
Mailing Address - Phone:574-946-2103
Mailing Address - Fax:574-946-2129
Practice Address - Street 1:101 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FRANCESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47946-8316
Practice Address - Country:US
Practice Address - Phone:219-567-9149
Practice Address - Fax:219-567-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267280Medicaid
IN155746Medicare Oscar/Certification