Provider Demographics
NPI:1952750606
Name:ST MARYS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:ST MARYS MEDICAL GROUP, LLC
Other - Org Name:ASCENSION MEDICAL GROUP ST. VINCENT EVANSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLIKAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:812-485-4000
Mailing Address - Street 1:PO BOX 13059
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4021
Mailing Address - Country:US
Mailing Address - Phone:317-583-3022
Mailing Address - Fax:317-583-2199
Practice Address - Street 1:3700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47750-0001
Practice Address - Country:US
Practice Address - Phone:812-485-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty