MEDICARE: ST JOSEPH MEDICAL CLINIC A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center	098	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255348843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOSEPH MEDICAL CLINIC A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 69
Second Line	:
City	:	VACHERIE
State	:	LA
Zip	:	70090-0069
Country	:	US
Telephone Number	:	225-265-3061
Fax Number	:	225-265-3062

Provider Business Practice Location Address
First Line	:	22080 LA HWY 20
Second Line	:
City	:	VACHERIE
State	:	LA
Zip	:	70090-0069
Country	:	US
Telephone Number	:	225-265-3061
Fax Number	:	225-265-3062

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAJA S TALLURI
Credential	:	M.D.
Telephone Number	:	225-265-3061

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/22/2020

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