Basic Information
| Provider Information | |||||||||
| NPI: | 1578517231 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPH HEALTH SYSTEM LLC | ||||||||
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| OtherOrganizationName: | ST. JOSEPH HOSPITAL GERO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15673 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144253000 | ||||||||
| FaxNumber: | 2604253222 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468021402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144253000 | ||||||||
| FaxNumber: | 2604253222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOSEPH HEALTH SYSTEM LLC | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 1052-0-AFR | IN | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 100268500C | 05 | IN | MEDICAID |