1013967736 NPI number — ST VINCENT PEDIATRIC SUBSPECIALTIES

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013967736 NPI number — ST VINCENT PEDIATRIC SUBSPECIALTIES

Employer Identification Number (EIN):

Provider Organization Name:

ST VINCENT PEDIATRIC SUBSPECIALTIES

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:

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:

1013967736

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

11/17/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

10330 N MERIDIAN ST

Provider Second Line Business Mailing Address:

SUITE 201

Provider Business Mailing Address City Name:

INDIANAPOLIS

Provider Business Mailing Address State Name:

IN

Provider Business Mailing Address Postal Code:

46290-1024

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

2001 W 86TH ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

INDIANAPOLIS

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

46260-1902

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

317-338-2273

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

05/11/2006

Authorized Official Last Name:

MCANDREWS

Authorized Official First Name:

KEVIN

Authorized Official Middle Name:

Authorized Official Title or Position:

VICE PRESIDENT

Authorized Official Telephone Number:

317-583-3194

• Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207XP3100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207YP0228X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 050050751 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080N0001X ; 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: 2080P0205X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0207X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0214X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2086S0120X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208M00000X ; 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" .

• Identifier: 200505130P , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200901000B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130M , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130S , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130U , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130Y , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130I , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130J , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130R , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130V , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130X , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130F , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130K , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130L , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130O , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130H , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130N , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200505130W , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".