MEDICARE: ST. VINCENT MADISON COUNTY HEALTH SYSTEM, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1477663847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. VINCENT MADISON COUNTY HEALTH SYSTEM, INC.

Provider Business Mailing Address
First Line	:	10330 N MERIDIAN ST
Second Line	:	SUITE 201
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46290-1024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 SKYVIEW DR
Second Line	:
City	:	CHESTERFIELD
State	:	IN
Zip	:	46017-1057
Country	:	US
Telephone Number	:	765-378-1572
Fax Number	:	765-378-1580

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	D. BRUCE HAGA
Credential	:
Telephone Number	:	317-583-3087

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	10/15/2007

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