Provider Demographics
NPI:1700858180
Name:ST. JOSEPH FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ST. JOSEPH FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-671-1331
Mailing Address - Street 1:2120 S RIVERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2535
Mailing Address - Country:US
Mailing Address - Phone:816-671-1331
Mailing Address - Fax:816-676-1311
Practice Address - Street 1:2120 S RIVERSIDE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2535
Practice Address - Country:US
Practice Address - Phone:816-671-1331
Practice Address - Fax:816-676-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503971103Medicaid
MO24542019OtherGROUP # FOR BCBS KC
MOH980000Medicare ID - Type Unspecified