SAINT CATHERINE PHYSICIANS SERVICES LLC

Provider Demographics

• NPI: 1790973030
• Name: SAINT CATHERINE PHYSICIANS SERVICES LLC
• Entity Type: Organization
• Organization Name: SAINT CATHERINE PHYSICIANS SERVICES LLC
• Other - Org Name: SAINT CATHERINE MEDICAL GROUP
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - First Name: KATHRYN
• Authorized Official - Middle Name: F
• Authorized Official - Last Name: PRIBBLE
• Authorized Official - Phone: 812-256-7579
• Mailing Address - Street 1: 2100 MARKET ST
• Mailing Address - Street 2: STE 106
• Mailing Address - City: CHARLESTOWN
• Mailing Address - State: IN
• Mailing Address - Zip Code: 47111
• Mailing Address - Country: US
• Mailing Address - Phone: 812-256-7830
• Mailing Address - Fax: 812-256-7835
• Practice Address - Street 1: 2100 MARKET ST.
• Practice Address - City: CHARLESTOWN
• Practice Address - State: IN
• Practice Address - Zip Code: 47111
• Practice Address - Country: US
• Practice Address - Phone: 812-256-7830
• Practice Address - Fax: 812-256-7835
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: SAINT CATHERINE PHYSICIAN SERVICES LLC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2007-10-11
• Last Update Date: 2009-02-02

Provider Licenses

State	License ID	Taxonomies
IN	01036818A	207R00000X
IN	01044677A	207R00000X
IN	10128535A	207RP1001X
IN	01031544A	208600000X
IN	01065372A	208600000X
IN	01064871A	2086S0129X
IN	71001236A	363L00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Single Specialty
No	207RP1001X	Allopathic & Osteopathic Physicians	Internal Medicine	Pulmonary Disease	Group - Single Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Single Specialty
No	2086S0129X	Allopathic & Osteopathic Physicians	Surgery	Vascular Surgery	Group - Single Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	100138490	Medicaid
IN	200406830	Medicaid
IN	100204700	Medicaid
IN	D95574	Other	UPIN
IN	000000549973	Other	ANTHEM BC/BS
IN	200879370A	Medicaid
IN	20087937A	Medicaid
IN	71001236A	Other	LISC
IN	200893060	Medicaid
IN	255620	Medicare UPIN
IN	P71128	Medicare UPIN
IN	676807	Medicare UPIN
IN	200406830	Medicaid
IN	B28860	Medicare UPIN
IN	255620	Medicare PIN