Basic Information
| Provider Information | |||||||||
| NPI: | 1144511866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT JOSEPH MEDICAL FOUNDATION, INC | ||||||||
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| OtherOrganizationName: | PREMIER ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73652 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593132758 | ||||||||
| FaxNumber: | 8592765939 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068640770 | ||||||||
| FaxNumber: | 6068641461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CARMEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 6063095506 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.