Organization
ST JOSEPH PRIMARY LLC
Active
Other names
Sycamore Primary & Specialty Care
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ANDREW KELLAR (REGIONAL PRACTICE ADMINISTRATOR)
(765) 457-8381
Entity
Organization
Contact information
Practice address
712 W MAIN ST, GREENTOWN, IN 46936-1045
(765) 628-3317
(765) 457-4443
Mailing address
712 W MAIN ST, GREENTOWN, IN 46936-1045
(765) 628-3317
(765) 457-4443
Taxonomy
Speciality
Code
Description
License number
State
173000000X
Legal Medicine
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000183518
BLUE CROSS BLUE SHIELD
IN
Enumeration date
05/27/2006
Last updated
11/16/2007
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