Provider Demographics
NPI:1871623041
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:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-521-1515
Mailing Address - Street 1:1400 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5832
Mailing Address - Country:US
Mailing Address - Phone:260-484-1558
Mailing Address - Fax:260-484-1550
Practice Address - Street 1:1400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5832
Practice Address - Country:US
Practice Address - Phone:260-484-1558
Practice Address - Fax:260-484-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08-000459-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100289700Medicaid
IN100289700Medicaid