=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568799732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. VINCENT SALEM HOSPITAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2009
-----------------------------------------------------
Last Update Date | 11/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 N SHELBY ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47167-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-583-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10330 N MERIDIAN ST SUITE 201
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46290-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | D. BRUCE HAGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-583-3087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------