Basic Information
| Provider Information | |||||||||
| NPI: | 1245270834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT PEDIATRIC REHABILITATION CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. VINCENT CHILDREN'S SPECIALTY HOSPITAL, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 W. 86TH ST. | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174155500 | ||||||||
| FaxNumber: | 3174155595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 W. 86TH ST. | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174155500 | ||||||||
| FaxNumber: | 3174155595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | POLTAWSKY | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3174155522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | IN | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.