Basic Information
| Provider Information | |||||||||
| NPI: | 1679578850 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT ANDERSON REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASCENSION ST. VINCENT ANDERSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2015 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656468243 | ||||||||
| FaxNumber: | 7656468655 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656468243 | ||||||||
| FaxNumber: | 7656468655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACOBSON | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3175827219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 332S00000X | N | Suppliers | Hearing Aid Equipment | 207P00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 282N00000X | 050050781 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 200408600R | 05 | IN | MEDICAID | 200409060 | 05 | IN | MEDICAID | 000000244149 | 01 | IN | ANTHEM HOME HEALTH PIN | OTHER | 200408600Q | 05 | IN | MEDICAID | CK6867 | 01 | IN | MEDICARE PIN OTHER ID | OTHER | 000000244683 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |