Provider Demographics
NPI:1356570014
Name:ST MARY MEDICAL CENTER INC
Entity type:Organization
Organization Name:ST MARY MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:SUDICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-942-0551
Mailing Address - Street 1:10607 RANDOLPH ST
Mailing Address - Street 2:STE A
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7504
Mailing Address - Country:US
Mailing Address - Phone:219-663-4007
Mailing Address - Fax:219-663-4198
Practice Address - Street 1:10607 RANDOLPH ST
Practice Address - Street 2:STE A
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7504
Practice Address - Country:US
Practice Address - Phone:219-663-4007
Practice Address - Fax:219-663-4198
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-02
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208200000X
IN02003280A208200000X
IN02003287A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty