Provider Demographics
NPI:1487854675
Name:ST. JOSEPH PRIMARY CARE LLC
Entity Type:Organization
Organization Name:ST. JOSEPH PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:OYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-457-8381
Mailing Address - Street 1:3109 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-4181
Mailing Address - Country:US
Mailing Address - Phone:765-457-8381
Mailing Address - Fax:765-457-4443
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-457-8381
Practice Address - Fax:765-457-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183506OtherBLUE CROSS BLUE SHIELD GR
IN170710Medicare PIN