Provider Demographics
NPI:1124126933
Name:ST. VINCENT PHYSICIAN NETWORK, LLC
Entity type:Organization
Organization Name:ST. VINCENT PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:D
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-338-7419
Mailing Address - Street 1:9588 VALPARAISO COURT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 REBEL DRIVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:IN
Practice Address - Zip Code:47355-8947
Practice Address - Country:US
Practice Address - Phone:765-874-2390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN220620Medicare ID - Type UnspecifiedGROUP MCR PART B NUMBER