Provider Demographics
NPI:1023203239
Name:ST. VINCENT HOSPITAL AND HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:ST. VINCENT HOSPITAL AND HEALTH CARE CENTER, INC.
Other - Org Name:ST. VINCENT PEDIATRIC SUBSPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-583-3087
Mailing Address - Street 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:800-727-8439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. VINCENT HOSPITAL AND HEALTH CARE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-11
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200505130WMedicaid
IN223110Medicare PIN