Provider Demographics
NPI:1962504175
Name:ST MARY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST MARY MEDICAL CENTER INC
Other - Org Name:ST MARY WOUND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KULLERSTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-934-8999
Mailing Address - Street 1:1600 S LAKE PARK AVE
Mailing Address - Street 2:STE 1103
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6641
Mailing Address - Country:US
Mailing Address - Phone:219-947-6448
Mailing Address - Fax:219-947-6839
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-947-6448
Practice Address - Fax:219-947-6839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-01
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060057861282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200031870Medicaid
IN263850Medicare PIN