1750336640 NPI number — DEACONESS HEART CENTER CATH LAB

Table of content: (NPI 1750336640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750336640 NPI number — DEACONESS HEART CENTER CATH LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS HEART CENTER CATH LAB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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 Information

NPI Number:
1750336640
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 W COLUMBIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47710-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-464-0547
Provider Business Mailing Address Fax Number:
812-464-4485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 W COLUMBIA ST
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:
47710-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-464-0547
Provider Business Practice Location Address Fax Number:
812-464-4485
Provider Enumeration Date:
05/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEPSIC
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHAIRMAN
Authorized Official Telephone Number:
812-464-9133

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000362389 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".