SAINT JOSEPH REGIONAL MEDICAL CENTER, INC.

Provider Demographics

• NPI: 1467406074
• Name: SAINT JOSEPH REGIONAL MEDICAL CENTER, INC.
• Entity Type: Organization
• Organization Name: SAINT JOSEPH REGIONAL MEDICAL CENTER, INC.
• Other - Org Name: SAINT JOSEPH PHYSICIAN NETWORK
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: CFO
• Authorized Official - Prefix: MR
• Authorized Official - First Name: ROBERT
• Authorized Official - Last Name: SINK
• Authorized Official - Phone: 574-335-4654
• Mailing Address - Street 1: 707 CEDAR ST STE 200
• Mailing Address - Street 2: SAINT JOSEPH PHYSICIAN NETWORK-CBO
• Mailing Address - City: SOUTH BEND
• Mailing Address - State: IN
• Mailing Address - Zip Code: 46617-2057
• Mailing Address - Country: US
• Mailing Address - Phone: 574-335-8700
• Mailing Address - Fax: 574-335-0741
• Practice Address - Street 1: 60101 BODNAR BLVD STE 100B
• Practice Address - City: MISHAWAKA
• Practice Address - State: IN
• Practice Address - Zip Code: 46544-9340
• Practice Address - Country: US
• Practice Address - Phone: 574-335-8500
• Practice Address - Fax: 574-335-0794
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: TRINITY HEALTH CORPORATION
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-05-19
• Last Update Date: 2022-12-16

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	207RI0200X	Allopathic & Osteopathic Physicians	Internal Medicine	Infectious Disease	Group - Multi-Specialty
No	207V00000X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology		Group - Multi-Specialty
No	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	261QU0200X	Ambulatory Health Care Facilities	Clinic/Center	Urgent Care	Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty
No	363LP0200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Pediatrics	Group - Multi-Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Multi-Specialty
No	363LA2200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Adult Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	000000215737	Other	ANTHEM
IN	000000219461	Other	ANTHEM
IN	000000219483	Other	ANTHEM
IN	000001245395	Other	ANTHEM
IN	100382620A	Medicaid
IN	100461640B	Medicaid
IN	100461640F	Medicaid
IN	300000754	Medicaid
IN	300046828	Medicaid
IN	000000271759	Other	ANTHEM
IN	100461640A	Medicaid
IN	300035149	Medicaid
IN	300046748	Medicaid
IN	000000219486	Other	ANTHEM
IN	000000219523	Other	ANTHEM
IN	100461640H	Medicaid
IN	000000219463	Other	ANTHEM
IN	000000878282	Other	ANTHEM
IN	000000982999	Other	ANTHEM
IN	100461640E	Medicaid
IN	200041520D	Medicaid
IN	000000215216	Other	ANTHEM
IN	000000219481	Other	ANTHEM
IN	000000219522	Other	ANTHEM
IN	000000732933	Other	ANTHEM
IN	300068646	Medicaid
IN	CJ6650	Other	RR MEDICARE
IN	000000215275	Other	ANTHEM
IN	100269960D	Medicaid
IN	100461640D	Medicaid
IN	100461640G	Medicaid
IN	200045130A	Medicaid
IN	300046826	Medicaid
IN	000000547396	Other	ANTHEM
IN	021236800	Other	FEDERAL BLACK LUNG
IN	100173780A	Medicaid
IN	200251600A	Medicaid
IN	300000752	Medicaid
IN	300025120	Medicaid