Provider Demographics
NPI:1245382498
Name:ST MARY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER INC
Other - Org Name:ST MARY CARE NETWORK PORTER COUNTY PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RYBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-942-0551
Mailing Address - Street 1:2000 ROOSEVELT RD
Mailing Address - Street 2:STE 5
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2800
Mailing Address - Country:US
Mailing Address - Phone:219-464-2123
Mailing Address - Fax:219-465-0032
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:STE 5
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-464-2123
Practice Address - Fax:219-465-0032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-17
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200219530AMedicaid
INC25439Medicare UPIN
IN090450Medicare PIN