MEDICARE: ST JOSEPH PRIMARY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000183518	OTHER	IN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780631812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOSEPH PRIMARY LLC

Provider Business Mailing Address
First Line	:	712 W MAIN ST
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1045
Country	:	US
Telephone Number	:	765-628-3317
Fax Number	:	765-457-4443

Provider Business Practice Location Address
First Line	:	712 W MAIN ST
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1045
Country	:	US
Telephone Number	:	765-628-3317
Fax Number	:	765-457-4443

Authorized Official
Title or Position	:	REGIONAL PRACTICE ADMINISTRATOR
Name	:	MR. ANDREW KELLAR
Credential	:
Telephone Number	:	765-457-8381

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	11/16/2007

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Directions to “ST JOSEPH PRIMARY LLC ” Practice Location

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