Healthcare Provider Details

I. General information

NPI: 1588986707
Provider Name (Legal Business Name): SAINT JOSEPH MEDICAL FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RICE ST
WILMORE KY
40390-1359
US

IV. Provider business mailing address

PO BOX 73652
CLEVELAND OH
44193-0002
US

V. Phone/Fax

Practice location:
  • Phone: 859-858-9355
  • Fax: 859-858-0416
Mailing address:
  • Phone: 606-330-3404
  • Fax: 606-330-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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