Healthcare Provider Details

I. General information

NPI: 1336342286
Provider Name (Legal Business Name): ST. JOSEPH PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 08/22/2020
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: 765-628-5979
Mailing address:
  • Phone: 765-628-3317
  • Fax: 765-628-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01060986A
License Number StateIN

VIII. Authorized Official

Name: DR. JAMES E. WHITFIELD
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 765-457-8381