Provider Demographics
NPI:1669633053
Name:ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC
Other - Org Name:BELLEMEADE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-1827
Mailing Address - Street 1:3801 BELLEMEADE AVE
Mailing Address - Street 2:SUITE 200-C
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0100
Mailing Address - Country:US
Mailing Address - Phone:812-485-1717
Mailing Address - Fax:
Practice Address - Street 1:3801 BELLEMEADE AVE
Practice Address - Street 2:SUITE 200-C
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0100
Practice Address - Country:US
Practice Address - Phone:812-485-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903430BMedicaid
IN200903430BMedicaid