1336236025 NPI number — SAINT JOHN HEALTH SYSTEM

Table of content: (NPI 1336236025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336236025 NPI number — SAINT JOHN HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAINT JOHN HEALTH SYSTEM
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:
1336236025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 JACKSON ST
Provider Second Line Business Mailing Address:
RM 248
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46016-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-683-3201
Provider Business Mailing Address Fax Number:
765-646-8625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 MERIDIAN ST
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46016-4346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-646-8366
Provider Business Practice Location Address Fax Number:
765-683-3202
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
DANTE
Authorized Official Middle Name:
O
Authorized Official Title or Position:
DME CONSULTANT
Authorized Official Telephone Number:
765-683-3201

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  69000167A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 69000167A , 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: 200408950 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000247286 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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