Provider Demographics
NPI:1164614723
Name:ST. VINCENT JENNINGS HOSPITAL, INC
Entity Type:Organization
Organization Name:ST. VINCENT JENNINGS HOSPITAL, INC
Other - Org Name:JENNINGS FAMILY CARE
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 1:301 HENRY ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1063
Practice Address - Country:US
Practice Address - Phone:812-352-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. VINCENT JENNINGS HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-16
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153991Medicare Oscar/Certification
IN178730Medicare PIN