Basic Information
| Provider Information | |||||||||
| NPI: | 1336315563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 W 86TH STREET | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462801902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173382281 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 W 86TH STREET | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462801902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173382281 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | ANDRES | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | ADAM | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3173457399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 11012731A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.