Provider Demographics
NPI:1477513844
Name:SAINT CHARLES SURGICAL PAVILION INC
Entity Type:Organization
Organization Name:SAINT CHARLES SURGICAL PAVILION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-634-1211
Mailing Address - Street 1:1900 SAINT CHARLES STREET
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9145
Mailing Address - Country:US
Mailing Address - Phone:812-634-1211
Mailing Address - Fax:812-634-9762
Practice Address - Street 1:1900 SAINT CHARLES STREET
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9145
Practice Address - Country:US
Practice Address - Phone:812-634-1211
Practice Address - Fax:812-634-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060025231261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200318370AMedicaid
IN200318370AMedicaid