Provider Demographics
NPI:1528160736
Name:ST MARY MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:ST MARY MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KULLERSTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-934-8994
Mailing Address - Street 1:PO BOX 3604
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-0703
Mailing Address - Country:US
Mailing Address - Phone:219-836-7370
Mailing Address - Fax:219-934-8889
Practice Address - Street 1:1437 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342
Practice Address - Country:US
Practice Address - Phone:219-947-6105
Practice Address - Fax:219-947-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060053791251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200009300AMedicaid
IN200009300AMedicaid