St Joseph Medical Group Inc
Organization Active NPI General Practice Physician · Fort Wayne, IN
NPI 1811952070 · NPPES record last updated Dec 15, 2015
Key facts
- NPI
- 1811952070
- Entity type
- Organization (NPI type 2)
- Primary specialty
- General Practice Physician 208D00000X
- Legal business name
- ST JOSEPH MEDICAL GROUP INC
- Practice address
- 2622 Lake Ave
Fort Wayne, IN 46805-5410 - Phone
- (260) 425-3100
- NPI assigned
- Apr 19, 2006
- Organization subpart
- No
Authorized official
- Name
- Sophia L Arwood
- Title
- Director of Physician Operations
- Phone
- (615) 628-6038
Other NPIs on the same Medicare enrollment 1
Corporate family (same tax ID) 1
Practitioners 45
-
Dorothea Addo, MD
-
John Addo, MD
-
Sarah A Brady, RN, MSN, NP-C
-
John B Brinkman, MD
-
Matthew A Byers, M.D.
-
Mark D Dabagia, MD
-
Michelle M Diss, NP
-
Pamela Kinder Fountain, MSN, RNC, APRN-BC
-
Minxin Fu, MD
-
Marcia K Grant, LCSW LMFT
-
Chelsea R Handshoe, N.P.
-
Ashraf H Hanna, MD
-
Kanika Jaggi, MD
-
Christopher B King, M.D.
-
Doyle Lorenz, MD
-
George L Martin, M.D.
-
Nizar Olabi, DO
-
Mahnaz Qazi, MD
-
Thomas P Ryan, DO
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040525001030 | IN | Part B Supplier - Clinic/Group Practice | 2264413491 |
Receives reassigned benefits from 35 practitioners 1 other NPI on this enrollment Practice locations: Angola, IN; Peru, IN; New Haven, IN; Fort Wayne, IN; Bluffton, IN |
National Provider Directory
- Tax ID family
- St Joseph Medical Group
Locations
800 Broadway
Ste 115
Fort Wayne, IN 46802
Phone (219) 425-3636
1211 W State Blvd
Fort Wayne, IN 46808
Phone (260) 422-0010
2700 Lafayette St
Ste B10
Fort Wayne, IN 46806
Phone (219) 744-7004
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker |
104100000X | |||
| Allergy & Immunology Physician |
207K00000X | |||
| Anesthesiology Physician |
207L00000X | |||
| Family Medicine Physician |
207Q00000X | |||
| Internal Medicine Physician |
207R00000X | |||
| Geriatric Medicine (Internal Medicine) Physician |
207RG0300X | |||
| Hematology & Oncology Physician |
207RH0003X | |||
| Pulmonary Disease Physician |
207RP1001X | |||
| Orthopaedic Surgery Physician |
207X00000X | |||
| Pediatrics Physician |
208000000X | |||
| Psychiatry Physician |
2084P0800X | |||
| General Practice Physician |
208D00000X | Yes | ||
| Physician Assistant |
363A00000X | |||
| Nurse Practitioner |
363L00000X |
Addresses
Primary practice location
2622 Lake Ave
Fort Wayne, IN 46805-5410
Mailing address
2622 Lake Ave
Fort Wayne, IN 46805-5410
Phone (260) 425-3100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2629570 | Medicaid | OH | |
| 100268520 | Medicaid | IN |
Other providers in Fort Wayne, IN
- Srisai P C
- SRT Prosthetics & Orthotics LLC
- St Joseph Health System LLC
- St Joseph Health System LLC
- St Joseph Health System LLC
- St. Joseph Health System LLC
- St. Joseph Health System, LLC
- St. Joseph Health System, LLC
- St. Joseph Township EMS
- St. Vincent Hospital and Health Care Center, Inc.
All providers in Fort Wayne, IN · General Practice Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 15, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.