Provider Demographics
NPI: | 1518361518 |
---|---|
Name: | ST MARYS MEDICAL GROUP, LLC |
Entity Type: | Organization |
Organization Name: | ST MARYS MEDICAL GROUP, LLC |
Other - Org Name: | ASCENSION MEDICAL GROUP ST. VINCENT EVANSVILLE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CFO (SVMG) |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BRIAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MORRIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 317-338-6234 |
Mailing Address - Street 1: | PO BOX 13059 |
Mailing Address - Street 2: | |
Mailing Address - City: | BELFAST |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04915-4021 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-583-3022 |
Mailing Address - Fax: | 317-583-2199 |
Practice Address - Street 1: | 3700 WASHINGTON AVE |
Practice Address - Street 2: | |
Practice Address - City: | EVANSVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47714-0541 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-485-4000 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-10-20 |
Last Update Date: | 2021-10-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103T00000X, 1041C0700X | ||
IN | 2084N0400X, 2084N0402X, 2084P0800X, 2080P0214X, 2084N0400X, 2084N0402X, 207VM0101X, 2080P0006X, 2084P0800X, 208600000X, 208G00000X, 363LP0200X, 208800000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2084N0402X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | Group - Multi-Specialty |
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2080P0214X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | Group - Multi-Specialty |
No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
No | 2080P0006X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental - Behavioral Pediatrics | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |