Provider Demographics
NPI:1306130109
Name:ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC
Entity type:Organization
Organization Name:ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:F
Authorized Official - Last Name:VOZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-1827
Mailing Address - Street 1:835 SOUTH 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAUBSTADT
Mailing Address - State:IN
Mailing Address - Zip Code:47639-0370
Mailing Address - Country:US
Mailing Address - Phone:812-485-1827
Mailing Address - Fax:
Practice Address - Street 1:835 SOUTH 9TH AVE
Practice Address - Street 2:
Practice Address - City:HAUBSTADT
Practice Address - State:IN
Practice Address - Zip Code:47639-0370
Practice Address - Country:US
Practice Address - Phone:812-485-1827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN257030Medicare PIN