Provider Demographics
NPI:1205037231
Name:ST. MARY'S AT HOME
Entity type:Organization
Organization Name:ST. MARY'S AT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-4079
Mailing Address - Street 1:PO BOX 15187
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-0187
Mailing Address - Country:US
Mailing Address - Phone:812-485-7950
Mailing Address - Fax:812-485-7724
Practice Address - Street 1:6840 LOGAN DR
Practice Address - Street 2:SUITE E
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8253
Practice Address - Country:US
Practice Address - Phone:812-485-7950
Practice Address - Fax:812-485-7724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN007035251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000222679OtherBLUE CROSS IV
IN157281Medicare ID - Type Unspecified