Provider Demographics
NPI:1720234883
Name:ST. VINCENT PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:ST. VINCENT PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-583-3087
Mailing Address - Street 1:2530 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1258 OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3377
Practice Address - Country:US
Practice Address - Phone:765-656-3830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5745510001Medicare NSC