1578556031 NPI number — ST VINCENT RANDOLPH HOSPITAL

Table of content: (NPI 1578556031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578556031 NPI number — ST VINCENT RANDOLPH HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST VINCENT RANDOLPH HOSPITAL
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:
1578556031
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:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47394-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-874-2390
Provider Business Mailing Address Fax Number:
765-584-0551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 REBEL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-874-2390
Provider Business Practice Location Address Fax Number:
765-584-0551
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DESCHAMBEAU
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
765-584-0141

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2281141 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000105462 . This is a "BC/BS GROUP #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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