Provider Demographics
NPI:1598839730
Name:ST. MARY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST. MARY MEDICAL CENTER INC
Other - Org Name:MICHAEL KOVACICH MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-942-0551
Mailing Address - Street 1:9660 WICKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-226-2203
Mailing Address - Fax:219-226-2202
Practice Address - Street 1:200 E 80TH PLACE
Practice Address - Street 2:STE 100
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5671
Practice Address - Country:US
Practice Address - Phone:219-769-7536
Practice Address - Fax:219-736-1506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200251650Medicaid
IN200251650Medicaid