Provider Demographics
NPI:1336342286
Name:ST. JOSEPH PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:ST. JOSEPH PRIMARY CARE, LLC
Other - Org Name:SYCAMORE PEDIATRICS AND ADOLESCENTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:765-628-5979
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:765-628-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060986A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1285615336OtherNPI
IN000000378656OtherBLUE CROSS BLUE SHIELD
INI38360Medicare UPIN
IN170710MMedicare ID - Type Unspecified