Provider Demographics
NPI:1912144791
Name:SAINT JOSEPH MEDICAL FOUNDATION, INC
Entity Type:Organization
Organization Name:SAINT JOSEPH MEDICAL FOUNDATION, INC
Other - Org Name:SAINT JOSEPH BEREA FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KANDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:REA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-330-3404
Mailing Address - Street 1:PO BOX 73652
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0002
Mailing Address - Country:US
Mailing Address - Phone:606-330-3404
Mailing Address - Fax:606-330-3100
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-986-2343
Practice Address - Fax:859-986-2344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT JOSEPH MEDICAL FOUNDATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100002060Medicaid