Provider Demographics
NPI:1609188598
Name:ST MARY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER INC
Other - Org Name:INNOVATIVE WOMENS HEALTH
Other - Org Type:Other Name
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 1:850 MARSH STREET
Practice Address - Street 2:SUITE C
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-6239
Practice Address - Country:US
Practice Address - Phone:219-462-3377
Practice Address - Fax:219-464-4530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200966140Medicaid
IN200966140Medicaid