Provider Demographics
NPI:1689620981
Name:ST ANTHONY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST ANTHONY MEDICAL CENTER
Other - Org Name:SAMC EMERGENCY ROOM PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-757-6103
Mailing Address - Street 1:1201 S MAIN ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8481
Mailing Address - Country:US
Mailing Address - Phone:219-757-6218
Mailing Address - Fax:219-681-6885
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-757-6218
Practice Address - Fax:219-681-6885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200293160Medicaid
IN138200Medicare ID - Type UnspecifiedGROUP ID