Basic Information
| Provider Information | |||||||||
| NPI: | 1306011796 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS WOMEN'S HOSPITAL OF SOUTHERN INDIANA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TRI STATE PERINATOLOGY AT THE WOMEN'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 637273 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452637273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424260 | ||||||||
| FaxNumber: | 8126023174 | ||||||||
| Practice Location | |||||||||
| Address1: | 4199 GATEWAY BLVD STE 3100 | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476307906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424550 | ||||||||
| FaxNumber: | 8128424549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8128424200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEACONESS WOMEN'S HOSPITAL OF SOUTHERN IN, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SP1700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Perinatal | 207VM0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200921280A | 05 | IN | MEDICAID |