Basic Information
| Provider Information | |||||||||
| NPI: | 1548596091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN PHYSICIANS HOSPITAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRANCISCAN PHYSICIANS HOSPITAL PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642107 | ||||||||
| FaxNumber: | 2198642251 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 SUPERIOR AVE | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199224001 | ||||||||
| FaxNumber: | 2199224020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2199224001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200932940 | 05 | IN | MEDICAID |