Provider Demographics
NPI:1033304241
Name:ST. VINCENT RANDOLPH HOSPITAL, INC.
Entity Type:Organization
Organization Name:ST. VINCENT RANDOLPH HOSPITAL, INC.
Other - Org Name:HOSPITALIST PROGRAM
Other - Org Type:Other Name
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 1:473 E GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-9436
Practice Address - Country:US
Practice Address - Phone:765-584-0339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2634117Medicaid
OH2634117Medicaid