1336342286 NPI number — ST. JOSEPH PRIMARY CARE, LLC

Table of content: (NPI 1336342286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336342286 NPI number — ST. JOSEPH PRIMARY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOSEPH PRIMARY CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336342286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENTOWN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46936-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-628-3317
Provider Business Mailing Address Fax Number:
765-628-5979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46936-1045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-628-3317
Provider Business Practice Location Address Fax Number:
765-628-5979
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITFIELD
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
765-457-8381

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  01060986A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1285615336 . This is a "NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000378656 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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