1063675759 NPI number — ST ELIZABETH MEDICAL CENTER INC

Table of content: (NPI 1063675759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063675759 NPI number — ST ELIZABETH MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST ELIZABETH MEDICAL CENTER INC
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:
ST ELIZABETH BUSINESS HEALTH CENTER
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 Information

NPI Number:
1063675759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6388808
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45264-8880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-301-5544
Provider Business Mailing Address Fax Number:
859-578-5975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 OLYMPIC BLVD.
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ERLANGER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-301-5544
Provider Business Practice Location Address Fax Number:
859-578-5975
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEGRIS
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS HEALTH
Authorized Official Telephone Number:
859-301-5599

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G2000000497265 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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