1164852539 NPI number — ST MARY'S MEDICAL GROUP, LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164852539 NPI number — ST MARY'S MEDICAL GROUP, LLC

Employer Identification Number (EIN):

Provider Organization Name:

ST MARY'S MEDICAL GROUP, LLC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

ST VINCENT EVANSVILLE MEDICAL GROUP

Provider Other Organization Name Type Code:

3

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1164852539

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

05/18/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 13059

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BELFAST

Provider Business Mailing Address State Name:

ME

Provider Business Mailing Address Postal Code:

04915-4021

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

317-583-3022

Provider Business Mailing Address Fax Number:

317-583-2199

Provider First Line Business Practice Location Address:

3700 WASHINGTON AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

EVANSVILLE

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

47750-0001

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

812-485-4000

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

11/20/2013

Authorized Official Last Name:

MORRIS

Authorized Official First Name:

BRIAN

Authorized Official Middle Name:

Authorized Official Title or Position:

CFO (SVMG)

Authorized Official Telephone Number:

317-338-6234

• Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363LA2100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .