1780687061 NPI number — ST. MARY'S AT HOME, LLC

Table of content: (NPI 1780687061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780687061 NPI number — ST. MARY'S AT HOME, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARY'S AT HOME, 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:
1780687061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 CADILLAC DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
153-777-0226
Provider Business Mailing Address Fax Number:
615-373-4457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7321 EAGLE CREST BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47715-8157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-774-9760
Provider Business Practice Location Address Fax Number:
812-475-1739
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ADKINS
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP CHIEF LEGAL OFFICER
Authorized Official Telephone Number:
615-309-5668

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  007035 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000222679 . This is a "BLUE CROSS INFUSION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100380190 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000194515 . This is a "BLUE CROSS HOME HEALTH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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