Provider Demographics
NPI:1134388168
Name:ST MARYS PHYSICIANS HEALTH GROUP LLC
Entity type:Organization
Organization Name:ST MARYS PHYSICIANS HEALTH GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-1827
Mailing Address - Street 1:8077 ROSE HILL DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2811
Mailing Address - Country:US
Mailing Address - Phone:812-853-7363
Mailing Address - Fax:812-853-5723
Practice Address - Street 1:8077 ROSE HILL DR
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2811
Practice Address - Country:US
Practice Address - Phone:812-853-7363
Practice Address - Fax:812-853-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001016A363LF0000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903430GMedicaid
257030Medicare PIN