Provider Demographics
NPI:1871605055
Name:ST PAUL HERMITAGE HOME
Entity type:Organization
Organization Name:ST PAUL HERMITAGE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:COONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-786-2261
Mailing Address - Street 1:501 N 17TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107
Mailing Address - Country:US
Mailing Address - Phone:317-786-2261
Mailing Address - Fax:317-782-1411
Practice Address - Street 1:501 N 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107
Practice Address - Country:US
Practice Address - Phone:317-786-2261
Practice Address - Fax:317-782-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060003911313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100274990AMedicaid