Basic Information
| Provider Information | |||||||||
| NPI: | 1174660526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS WOMEN'S HOSPITAL OF SOUTHERN INDIANA LLC | ||||||||
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| OtherOrganizationName: | NEONATOLOGY SERVICES FOR THE WOMEN'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637273 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452637273 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4199 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8128424200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEACONESS WOMEN'S HOSPITAL OF SOUTHERN INDIANA LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LN0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0005X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200437460A | 05 | IN | MEDICAID |