Provider Demographics
NPI:1205975851
Name:ST. JOSEPH HOSPITAL, LLC
Entity type:Organization
Organization Name:ST. JOSEPH HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:502-596-6063
Mailing Address - Street 1:680 S 4TH ST
Mailing Address - Street 2:LICENSE AND CERTIFICATION
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-212-8481
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-799-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805015100Medicaid
ID01347OtherBLUE CROSS ID MENTAL HEA
WA2081804Medicaid
WA0008481OtherWA L&I MENTAL HEALTH
ID72055OtherREGENCE OF ID MENTAL HEAL
WA3500097Medicaid