Basic Information
| Provider Information | |||||||||
| NPI: | 1356435341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN HEALTH LAFAYETTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRANCISCAN ST. ELIZABETH HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 S CREASY LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655024000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 S CREASY LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655024000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7655024440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 060050961 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100269040A | 05 | IN | MEDICAID |