MEDICARE: ST. VINCENT CHILDREN'S SPECIALTY HOSPITAL, 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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1730239849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. VINCENT CHILDREN'S SPECIALTY HOSPITAL, INC.

Provider Business Mailing Address
First Line	:	PO BOX 68952
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-0952
Country	:	US
Telephone Number	:	317-870-6740
Fax Number	:	317-870-0499

Provider Business Practice Location Address
First Line	:	1707 W 86TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-2002
Country	:	US
Telephone Number	:	317-415-5500
Fax Number	:

Authorized Official
Title or Position	:	ASST VP FINANCE
Name	:	ROLAND FUNSTEN
Credential	:
Telephone Number	:	317-338-8198

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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