Healthcare Provider Details

I. General information

NPI: 1063745081
Provider Name (Legal Business Name): SAINT JOSEPH MEDICAL FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 ESTILL ST 3RD FLOOR
BEREA KY
40403-1742
US

IV. Provider business mailing address

PO BOX 73652
CLEVELAND OH
44193-0002
US

V. Phone/Fax

Practice location:
  • Phone: 859-985-8100
  • Fax: 859-986-6571
Mailing address:
  • Phone: 606-330-3404
  • Fax: 606-330-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: KANDI R REA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 606-330-3404