Organization
ST JOSEPH PRIMARY LLC
Active
Other names
Sycamore Pediatrics & Adolescents
Organization subpart
No
Provider details
NPI number
Authorized official
ANDREW KELLAR (REGIONAL PRACTICE ADMINISTRATOR)
(765) 457-8381
Entity
Organization
Contact information
Practice address
3109 W SYCAMORE ST, KOKOMO, IN 46901-4026
(765) 457-8381
(765) 457-4443
Mailing address
3109 W SYCAMORE ST, KOKOMO, IN 46901-4026
(765) 457-8381
(765) 457-4443
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000183506
BLUE CROSS BLUE SHIELD
IN
Enumeration date
05/26/2006
Last updated
11/16/2007
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