Healthcare Provider Details

I. General information

NPI: 1841571718
Provider Name (Legal Business Name): ST JOSEPH CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 GUNBARREL RD SUITE 108
CHATTANOOGA TN
37421-4144
US

IV. Provider business mailing address

1102 W WAUGH ST
DALTON GA
30720-8769
US

V. Phone/Fax

Practice location:
  • Phone: 706-277-2321
  • Fax: 706-428-2812
Mailing address:
  • Phone: 706-277-2321
  • Fax: 706-428-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD0000045277
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1993
License Number StateTN

VIII. Authorized Official

Name: DR. PABLO E PEREZ
Title or Position: PRESIDENT
Credential: MD
Phone: 706-277-2321