=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124459573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. VINCENT MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2013
-----------------------------------------------------
Last Update Date | 12/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7408 W STATE ROAD 28 SUITE 1
-----------------------------------------------------
City | ELWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46036-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-557-2240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10330 N MERIDIAN ST SUITE 201
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46290-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-583-3078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | BRADLEY MCNABB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-583-3078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------