Provider Demographics
NPI:1952452815
Name:HENRY COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:HENRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO OF ASC
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-788-2500
Mailing Address - Street 1:2630 S KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-5563
Mailing Address - Country:US
Mailing Address - Phone:317-787-8951
Mailing Address - Fax:317-780-2550
Practice Address - Street 1:2630 S KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-787-8951
Practice Address - Fax:317-780-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-004700-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100266630CMedicaid
IN100266630CMedicaid
IN15-5741Medicare PIN