Healthcare Provider Details

I. General information

NPI: 1740234111
Provider Name (Legal Business Name): ST JOSEPH HEALTH SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BROADWAY
FORT WAYNE IN
46802-1402
US

IV. Provider business mailing address

15819 COLLECTION CENTER DR
CHICAGO IL
60693-0158
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-3000
  • Fax: 260-425-3222
Mailing address:
  • Phone: 260-425-3000
  • Fax: 260-425-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number05-005043-1
License Number StateIN

VIII. Authorized Official

Name: PAULA M LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 629-215-3953