Provider Demographics
NPI:1952812034
Name:DAVIESS COUNTY HOSPITAL
Entity Type:Organization
Organization Name:DAVIESS COUNTY HOSPITAL
Other - Org Name:THE LAURELS OF GOSHEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-254-2760
Mailing Address - Street 1:1480 SANDPIPER LN
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-7005
Mailing Address - Country:US
Mailing Address - Phone:317-653-5767
Mailing Address - Fax:
Practice Address - Street 1:1480 SANDPIPER LN
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-7005
Practice Address - Country:US
Practice Address - Phone:317-653-5767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0161052010-000OtherINDIANA DEPARTMENT OF REVENUE ID
IN300012886Medicaid