Provider Demographics
NPI:1124062419
Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:8128-863-5881
Mailing Address - Street 1:911 N. SHELBY ST.
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-2304
Mailing Address - Country:US
Mailing Address - Phone:812-883-5881
Mailing Address - Fax:812-883-8557
Practice Address - Street 1:911 N. SHELBY ST.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-2304
Practice Address - Country:US
Practice Address - Phone:812-883-5881
Practice Address - Fax:812-883-8557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207P00000X, 207Q00000X, 207V00000X, 207X00000X, 2085R0202X, 208VP0000X, 275N00000X, 3416L0300X, 363L00000X
IN0050871282NC0060X
IN07-005087-1282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No3416L0300XTransportation ServicesAmbulanceLand Transport
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200009980AMedicaid
IN200009980EMedicaid
IN000000054337OtherBLUE CROSS PROVIDER #
IN100269720Medicaid
IN200009980DMedicaid
IN200009980GMedicaid
IN200009980BMedicaid
IN030969400OtherFEDERAL BLACK LUNG
IN100269720AMedicaid
IN200009980CMedicaid
IN200009980FMedicaid
IN940950OtherMEDICARE PART B
IN100367960AMedicaid
IN030969400OtherFEDERAL BLACK LUNG
IN100269720Medicaid
IN200009980CMedicaid
IN200009980DMedicaid