Provider Demographics
NPI:1073569364
Name:ST JOSEPH PRIMARY LLC
Entity Type:Organization
Organization Name:ST JOSEPH PRIMARY LLC
Other - Org Name:MED ONE OF ST JOSEPH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-457-8381
Mailing Address - Street 1:5111 CLINTON DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-7136
Mailing Address - Country:US
Mailing Address - Phone:765-453-8800
Mailing Address - Fax:765-457-4443
Practice Address - Street 1:5111 CLINTON DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-7136
Practice Address - Country:US
Practice Address - Phone:765-453-8800
Practice Address - Fax:765-457-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20031200Medicaid
IN000000183506OtherBLUE CROSS BLUE SHIELD
IN20031200Medicaid