Provider Demographics
NPI:1952486862
Name:SAINT CHARLES SURGICAL PAVILION INC
Entity Type:Organization
Organization Name:SAINT CHARLES SURGICAL PAVILION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-634-1211
Mailing Address - Street 1:1900 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9145
Mailing Address - Country:US
Mailing Address - Phone:812-634-1211
Mailing Address - Fax:812-634-9762
Practice Address - Street 1:1900 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9145
Practice Address - Country:US
Practice Address - Phone:812-634-1211
Practice Address - Fax:812-634-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200339100AMedicaid
IN180560Medicare PIN