Provider Demographics
NPI:1215102066
Name:SAINT VINCENT OF MADISON COUNTY
Entity type:Organization
Organization Name:SAINT VINCENT OF MADISON COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:O
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-683-3201
Mailing Address - Street 1:2020 MERIDIAN ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4346
Mailing Address - Country:US
Mailing Address - Phone:765-683-3201
Mailing Address - Fax:765-646-8625
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-236-8300
Practice Address - Fax:765-236-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000392A332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200408950AMedicaid
IN6110830001Medicare NSC