Provider Demographics
NPI:1730136458
Name:ST. VINCENT WILLIAMSPORT HOSPITAL
Entity Type:Organization
Organization Name:ST. VINCENT WILLIAMSPORT HOSPITAL
Other - Org Name:ST. VINCENT SOUTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARLATT
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:765-762-4000
Mailing Address - Street 1:440 W SONGER LN
Mailing Address - Street 2:
Mailing Address - City:VEEDERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47987-8547
Mailing Address - Country:US
Mailing Address - Phone:765-294-2486
Mailing Address - Fax:
Practice Address - Street 1:440 W SONGER LN
Practice Address - Street 2:
Practice Address - City:VEEDERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47987-8547
Practice Address - Country:US
Practice Address - Phone:765-294-2486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. VINCENT WILLIAMSPORT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050050921261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200307100BMedicaid
IN250670Medicare PIN
IN200307100BMedicaid