Provider Demographics
NPI:1073502290
Name:ST MARY'S BREAST CENTER, LLC
Entity type:Organization
Organization Name:ST MARY'S BREAST CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-471-1591
Mailing Address - Street 1:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0138
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:100 ST MARYS EPWORTH XING
Practice Address - Street 2:STE. A500
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-9698
Practice Address - Country:US
Practice Address - Phone:812-485-4437
Practice Address - Fax:812-485-6890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SETON HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-20
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100468730Medicaid
KY7100138240Medicaid
KY7100138240Medicaid