Healthcare Provider Details

I. General information

NPI: 1982736377
Provider Name (Legal Business Name): ST. JOSEPH PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

IV. Provider business mailing address

3109 W SYCAMORE ST
KOKOMO IN
46901-4181
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-5433
  • Fax:
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 Number742949291
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

Name: BRIAN MORRIS
Title or Position: CFO (AMG)
Credential:
Phone: 317-338-6234