Provider Demographics
NPI:1578556031
Name:ST VINCENT RANDOLPH HOSPITAL
Entity Type:Organization
Organization Name:ST VINCENT RANDOLPH HOSPITAL
Other - Org Name:FAMILY AND OCCUPATIONAL MEDICINE OF LYNN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DESCHAMBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-584-0141
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-0428
Mailing Address - Country:US
Mailing Address - Phone:765-874-2390
Mailing Address - Fax:765-584-0551
Practice Address - Street 1:4 REBEL DRIVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:IN
Practice Address - Zip Code:47355
Practice Address - Country:US
Practice Address - Phone:765-874-2390
Practice Address - Fax:765-584-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2281141Medicaid
IN000000105462OtherBC/BS GROUP #
IN168830Medicare ID - Type UnspecifiedMEDICARE GROUP #
IN2281141Medicaid
INCB3976Medicare ID - Type UnspecifiedMEDICARE RR #