Provider Demographics
NPI:1962577346
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-947-0551
Mailing Address - Street 1:164 BRACKEN PKWY
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6789
Mailing Address - Country:US
Mailing Address - Phone:219-942-1145
Mailing Address - Fax:219-942-8175
Practice Address - Street 1:164 BRACKEN PKWY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6789
Practice Address - Country:US
Practice Address - Phone:219-942-1145
Practice Address - Fax:219-942-8175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200251650AMedicaid
IN142650Medicare PIN