Basic Information
| Provider Information | |||||||||
| NPI: | 1316991847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT INFIRMARY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ST VINCENT NORTH ANESTHESIA GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 WILDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SHERWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721205089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015527100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | CARPENTER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5015523155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 149329002 | 05 | AR | MEDICAID | 5C759 | 01 | AR | BLUE CROSS OF AR | OTHER | 171943200 | 01 | AR | US DEPT OF LABOR | OTHER |