Healthcare Provider Details

I. General information

NPI: 1821081456
Provider Name (Legal Business Name): ST VINCENT RANDOLPH HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N COLUMBIA ST
UNION CITY IN
47390-9496
US

IV. Provider business mailing address

PO BOX 428
WINCHESTER IN
47394-0428
US

V. Phone/Fax

Practice location:
  • Phone: 765-964-6200
  • Fax: 765-584-0551
Mailing address:
  • Phone: 765-964-6200
  • Fax: 765-584-0551

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. WAYNE G DESCHAMBEAU
Title or Position: ADMINISTRATOR
Credential:
Phone: 765-584-0141