1295996684 NPI number — ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC

Table of content: (NPI 1295996684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295996684 NPI number — ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARY'S PHYSICIANS' HEALTH 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's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1295996684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 BELLEMEADE AVE
Provider Second Line Business Mailing Address:
SUITE 200-A
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47714-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-485-1796
Provider Business Mailing Address Fax Number:
812-485-1790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 BELLEMEADE AVE
Provider Second Line Business Practice Location Address:
SUITE 200-A
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47714-0100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-485-1796
Provider Business Practice Location Address Fax Number:
812-485-1790
Provider Enumeration Date:
06/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KEIL
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
812-485-1827

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 71001430A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200903430D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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