Organization
ST VINCENT RANDOLPH HOSPITAL
Active
Other names
Family and Occupational Medicine of Ridgeville
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WAYNE G DESCHAMBEAU (ADMINISTRATOR)
(765) 584-0141
Entity
Organization
Contact information
Practice address
105 E 2ND ST, RIDGEVILLE, IN 47380-1325
(765) 857-2523
(765) 584-0551
Mailing address
PO BOX 428, WINCHESTER, IN 47394-0428
(765) 857-2523
(765) 584-0551
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000105462
BC/BS GROUP #
IN
05
—
2281123
—
IN
Enumeration date
08/30/2005
Last updated
08/22/2020
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