Provider Demographics
NPI:1780631812
Name:ST JOSEPH PRIMARY LLC
Entity Type:Organization
Organization Name:ST JOSEPH PRIMARY LLC
Other - Org Name:SYCAMORE PRIMARY & SPECIALTY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
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 1:712 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-1045
Mailing Address - Country:US
Mailing Address - Phone:765-628-3317
Mailing Address - Fax:765-457-4443
Practice Address - Street 1:712 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-1045
Practice Address - Country:US
Practice Address - Phone:765-628-3317
Practice Address - Fax:765-457-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183518OtherBLUE CROSS BLUE SHIELD
IN000000183518OtherBLUE CROSS BLUE SHIELD