Healthcare Provider Details

I. General information

NPI: 1487760849
Provider Name (Legal Business Name): SAINT JOHN'S HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VILLAGE DR
PENDLETON IN
46064-8960
US

IV. Provider business mailing address

75 VILLAGE DR
PENDLETON IN
46064-8960
US

V. Phone/Fax

Practice location:
  • Phone: 765-778-0913
  • Fax: 765-778-1374
Mailing address:
  • Phone: 765-778-0913
  • Fax: 765-778-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAMES W MOORE
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 765-646-8105