Basic Information
| Provider Information | |||||||||
| NPI: | 1073678330 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEWISH HOSPITAL & ST. MARY'S HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEWISH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2587 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402012587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | CLAGG | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5025608357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 100215 | KY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0485429 | 01 | KY | AETNA HMO | OTHER | 100275640A | 05 | IN | MEDICAID | 01022367 | 05 | KY | MEDICAID | 000000054799 | 01 | KY | ANTHEM | OTHER | 304657327 | 05 | MI | MEDICAID | 000000032104 | 05 | MA | MEDICAID | 1049530 | 01 | KY | PASSPORT | OTHER | 5000027 | 01 | KY | UNITED HEALTHCARE | OTHER | 2432563000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 006895400 | 01 | KY | BLACK LUNG | OTHER |