Basic Information
| Provider Information | |||||||||
| NPI: | 1780687061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S AT HOME, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION AT HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CADILLAC DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370271001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1537770226 | ||||||||
| FaxNumber: | 6153734457 | ||||||||
| Practice Location | |||||||||
| Address1: | 7321 EAGLE CREST BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127749760 | ||||||||
| FaxNumber: | 8124751739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADKINS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP CHIEF LEGAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6153095668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 007035 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000000222679 | 01 | IN | BLUE CROSS INFUSION | OTHER | 100380190 | 05 | IN | MEDICAID | 000000194515 | 01 | IN | BLUE CROSS HOME HEALTH | OTHER |