Provider Demographics
NPI:1902017080
Name:COMMUNITY HOSPITAL OF BREMEN, INC.
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL OF BREMEN, INC.
Other - Org Name:COMMUNITY HOSPITAL OF BREMEN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:574-546-2211
Mailing Address - Street 1:1020 HIGH ROAD
Mailing Address - Street 2:P.O. BOX 8
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506
Mailing Address - Country:US
Mailing Address - Phone:574-546-2211
Mailing Address - Fax:574-546-4312
Practice Address - Street 1:1020 HIGH ROAD
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506
Practice Address - Country:US
Practice Address - Phone:574-546-2211
Practice Address - Fax:574-546-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005097-1207P00000X
IN15-005097-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100269320AMedicaid
IN200011480AMedicaid
IN200011480AMedicaid