Provider Demographics
NPI:1801851902
Name:ST JOSEPH MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ST JOSEPH MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:1109 W MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-1329
Mailing Address - Country:US
Mailing Address - Phone:260-665-2131
Mailing Address - Fax:
Practice Address - Street 1:1109 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1329
Practice Address - Country:US
Practice Address - Phone:260-665-2131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100268520Medicaid
IN150930Medicare PIN