MEDICARE: ST. VINCENT PHYSICIAN NETWORK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063587400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. VINCENT PHYSICIAN NETWORK, LLC

Provider Business Mailing Address
First Line	:	9588 VALPARAISO CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1130
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 E 2ND ST
Second Line	:
City	:	RIDGEVILLE
State	:	IN
Zip	:	47380-1325
Country	:	US
Telephone Number	:	765-857-2523
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	D BRUCE HAGA
Credential	:
Telephone Number	:	317-338-7419

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	08/22/2020

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