1639352610 NPI number — ST CATHERINE PHYSICIAN SERVICES, LLC

Table of content: (NPI 1639352610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639352610 NPI number — ST CATHERINE PHYSICIAN SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CATHERINE PHYSICIAN SERVICES, 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:
1639352610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 MARKET ST.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47111-9535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-256-9714
Provider Business Mailing Address Fax Number:
812-256-9702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MARKET ST.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHARLESTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47111-9535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-256-9714
Provider Business Practice Location Address Fax Number:
812-256-9702
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAULBEE
Authorized Official First Name:
ROSIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PHYSICIAN PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
812-256-7436

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  01027298A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 01028535A , 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: 000000549974 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: B28860 . This is a "UPIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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