Healthcare Provider Details

I. General information

NPI: 1104866136
Provider Name (Legal Business Name): ST JOSEPH PRIMARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 W SYCAMORE ST
KOKOMO IN
46901-4026
US

IV. Provider business mailing address

3109 W SYCAMORE ST
KOKOMO IN
46901-4026
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-8381
  • Fax: 765-457-4443
Mailing address:
  • Phone: 765-457-8381
  • Fax: 765-457-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIN

VIII. Authorized Official

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