Healthcare Provider Details

I. General information

NPI: 1740589860
Provider Name (Legal Business Name): ST. VINCENT PHYSICIAN SERVICES HOSPITAL AND HEALTH CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8227 NORTHWEST BLVD SUITE 160
INDIANAPOLIS IN
46278-1387
US

IV. Provider business mailing address

10330 N MERIDIAN ST SUITE 201
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-5795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KYLE DEFUR
Title or Position: PRESIDENT
Credential:
Phone: 317-338-7031