Healthcare Provider Details

I. General information

NPI: 1073569364
Provider Name (Legal Business Name): ST JOSEPH PRIMARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 CLINTON DR
KOKOMO IN
46902-7136
US

IV. Provider business mailing address

5111 CLINTON DR
KOKOMO IN
46902-7136
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-8800
  • Fax: 765-457-4443
Mailing address:
  • Phone: 765-453-8800
  • Fax: 765-457-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

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