# WITHAM MEMORIAL HOSPITAL

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- **Entity:** Organization
- **Status:** Active
- **Other names:** St. Mary Healthcare Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174768618
- **Authorized official:** KELLY BRAVERMAN (CEO, PRESIDENT)
- **Authorized official phone:** (765) 485-8100

## Contact information

- **Practice address:** 2201 CASON ST, LAFAYETTE, IN 47904-2613
- **Practice address phone:** (765) 447-4102
- **Practice address fax:** (765) 447-7386
- **Mailing address:** PO BOX 221648, LOUISVILLE, KY 40252-1648
- **Mailing address phone:** (502) 412-5847

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 08-000037-1 | IN | Yes |

## Other

- **Enumeration date:** 12/12/2008
- **Last updated:** 03/26/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100291350 | — | IN |