Healthcare Provider Details

I. General information

NPI: 1154933703
Provider Name (Legal Business Name): ST MARY'S MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 BELLEMEADE AVE STE 110
EVANSVILLE IN
47714-0111
US

IV. Provider business mailing address

250 W 96TH ST STE 520
INDIANAPOLIS IN
46260-1317
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-7330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL PAROD
Title or Position: CEO
Credential:
Phone: 812-485-1502