Provider Demographics
NPI:1578517231
Name:ST JOSEPH HEALTH SYSTEM LLC
Entity Type:Organization
Organization Name:ST JOSEPH HEALTH SYSTEM LLC
Other - Org Name:ST. JOSEPH HOSPITAL GERO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:PO BOX 15673
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0156
Mailing Address - Country:US
Mailing Address - Phone:214-425-3000
Mailing Address - Fax:260-425-3222
Practice Address - Street 1:700 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1402
Practice Address - Country:US
Practice Address - Phone:214-425-3000
Practice Address - Fax:260-425-3222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH HEALTH SYSTEM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1052-0-AFR273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100268500CMedicaid
15S047Medicare Oscar/Certification