Provider Demographics
NPI:1841571718
Name:ST JOSEPH CLINIC, P.C.
Entity Type:Organization
Organization Name:ST JOSEPH CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-277-2321
Mailing Address - Street 1:1102 W WAUGH ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8769
Mailing Address - Country:US
Mailing Address - Phone:706-277-2321
Mailing Address - Fax:706-428-2812
Practice Address - Street 1:1720 GUNBARREL RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4144
Practice Address - Country:US
Practice Address - Phone:706-277-2321
Practice Address - Fax:706-428-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000045277207R00000X
TN1993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty