Provider Demographics
NPI:1770533994
Name:ST. VINCENT CLAY HOSPITAL, INC
Entity type:Organization
Organization Name:ST. VINCENT CLAY HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-442-2602
Mailing Address - Street 1:1206 E NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-2718
Mailing Address - Country:US
Mailing Address - Phone:812-442-2500
Mailing Address - Fax:
Practice Address - Street 1:1206 E NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2718
Practice Address - Country:US
Practice Address - Phone:812-442-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207Q00000X, 363L00000X, 363LF0000X
IN060050461261Q00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200348850AMedicaid
IN200107350Medicaid
IN940140Medicare PIN
IN151309Medicare Oscar/Certification