Healthcare Provider Details

I. General information

NPI: 1780631812
Provider Name (Legal Business Name): ST JOSEPH PRIMARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 W MAIN ST
GREENTOWN IN
46936-1045
US

IV. Provider business mailing address

712 W MAIN ST
GREENTOWN IN
46936-1045
US

V. Phone/Fax

Practice location:
  • Phone: 765-628-3317
  • Fax: 765-457-4443
Mailing address:
  • Phone: 765-628-3317
  • Fax: 765-457-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW KELLAR
Title or Position: REGIONAL PRACTICE ADMINISTRATOR
Credential:
Phone: 765-457-8381