Provider Demographics
NPI:1396816161
Name:DEKALB MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:DEKALB MEMORIAL HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING COLLECTION MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:260-920-2794
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-0623
Mailing Address - Country:US
Mailing Address - Phone:260-868-5843
Mailing Address - Fax:260-868-5844
Practice Address - Street 1:409 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:IN
Practice Address - Zip Code:46721-1175
Practice Address - Country:US
Practice Address - Phone:260-868-5843
Practice Address - Fax:260-868-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2463909Medicaid
IN100104110BMedicaid
INCC4531OtherRAILROAD MEDICARE
INCC4531OtherRAILROAD MEDICARE