Provider Demographics
NPI:1144466392
Name:SAINT JOSEPH MEDICAL FOUNDATION, INC
Entity type:Organization
Organization Name:SAINT JOSEPH MEDICAL FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN CREDENTIALING
Authorized Official - Prefix:MRS
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 2:3RD FLOOR
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-986-6791
Practice Address - Fax:606-330-3100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT JOSEPH MEDICAL FOUNDATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28530207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty