Provider Demographics
NPI:1366748386
Name:WITHAM MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:WITHAM MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-485-8100
Mailing Address - Street 1:PO BOX 221648
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-1648
Mailing Address - Country:US
Mailing Address - Phone:502-412-5847
Mailing Address - Fax:
Practice Address - Street 1:269 MEADOWVIEW DR
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-8996
Practice Address - Country:US
Practice Address - Phone:765-472-8049
Practice Address - Fax:765-475-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201021970Medicaid
IN201021970AMedicaid