Basic Information
| Provider Information | |||||||||
| NPI: | 1811047434 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT JOHNS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST JOHNS HEALTH SYSTEM DME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 01/12/2007 | ||||||||
| LastUpdateDate: | 07/06/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7656468243 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 07-005078-1 | IN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 200408940A | 05 | IN | MEDICAID |