Provider Demographics
NPI:1265489975
Name:ST JOSEPH PRIMARY LLC
Entity Type:Organization
Organization Name:ST JOSEPH PRIMARY LLC
Other - Org Name:KOKOMO GASTROENTEROLOGY & HEPATOLOGY
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 1:615 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-1890
Mailing Address - Country:US
Mailing Address - Phone:765-236-0610
Mailing Address - Fax:
Practice Address - Street 1:615 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-1890
Practice Address - Country:US
Practice Address - Phone:765-236-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0104783A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20031200FMedicaid
IN20031200FMedicaid