Healthcare Provider Details

I. General information

NPI: 1124253901
Provider Name (Legal Business Name): ST. VINCENT PHYSICIAN NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HENRY ST BLDG B
NORTH VERNON IN
47265-1030
US

IV. Provider business mailing address

10330 N MERIDIAN ST STE 300
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 812-352-4300
  • Fax:
Mailing address:
  • Phone: 317-583-3079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. D. BRUCE HAGA
Title or Position: VICE PRESIDENT
Credential:
Phone: 317-583-3079