Healthcare Provider Details

I. General information

NPI: 1619307873
Provider Name (Legal Business Name): ST MARY'S MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 WASHINGTON AVE
EVANSVILLE IN
47750-0001
US

IV. Provider business mailing address

PO BOX 13059
BELFAST ME
04915-4021
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-4000
  • Fax:
Mailing address:
  • Phone: 317-583-3022
  • Fax: 317-583-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM J MILLIKAN
Title or Position: CEO
Credential:
Phone: 812-485-4000