Provider Demographics
NPI:1760442883
Name:ST. MARY'S FREESTANDING CATH LAB LLC
Entity Type:Organization
Organization Name:ST. MARY'S FREESTANDING CATH LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERNEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-4573
Mailing Address - Street 1:PO BOX 15253
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-0253
Mailing Address - Country:US
Mailing Address - Phone:812-204-8429
Mailing Address - Fax:812-485-7416
Practice Address - Street 1:901 SAINT MARYS DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0520
Practice Address - Country:US
Practice Address - Phone:812-485-7409
Practice Address - Fax:812-485-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36001378Medicaid
KY36001378Medicaid
IL=========001Medicaid