Provider Demographics
NPI:1659558773
Name:DEACONESS WOMEN'S HOSPITAL OF SOUTHERN IN, LLC
Entity Type:Organization
Organization Name:DEACONESS WOMEN'S HOSPITAL OF SOUTHERN IN, LLC
Other - Org Name:MATERNAL FETAL MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-842-4200
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3239
Mailing Address - Country:US
Mailing Address - Phone:812-858-4620
Mailing Address - Fax:812-858-4621
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:STE 2600
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8940
Practice Address - Country:US
Practice Address - Phone:812-858-4620
Practice Address - Fax:812-858-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherTIN