Basic Information
| Provider Information | |||||||||
| NPI: | 1891820817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRANCISCAN ST FRANCIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRANCISCAN ST FRANCIS HEALTH BEHAVIORAL HEALTH OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284254 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 E SOUTHPORT RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462278592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177838383 | ||||||||
| FaxNumber: | 3177826929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | LAUTER | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3175288260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200023750A | 05 | IN | MEDICAID | 100057420B | 05 | IN | MEDICAID |