Basic Information
| Provider Information | |||||||||
| NPI: | 1619307873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY'S MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | ASCENSION MEDICAL GROUP ST. VINCENT EVANSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13059 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175833022 | ||||||||
| FaxNumber: | 3175832199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124854000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2013 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLIKAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124854000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.