| St Joseph Medical Group Inc | |
|
2622 Lake Ave Fort Wayne IN 46805-5410 | |
| (260) 425-3100 | |
| Not Available |
| Full Name | St Joseph Medical Group Inc |
|---|---|
| Speciality | General Practice |
| Location | 2622 Lake Ave, Fort Wayne, Indiana |
| Authorized Official Name and Position | Sophia L Arwood (DIRECTOR OF PHYSICIAN OPERATIONS) |
| Authorized Official Contact | 6156286038 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| St Joseph Medical Group Inc 2622 Lake Ave Fort Wayne IN 46805-5410 Ph: (260) 425-3100 | St Joseph Medical Group Inc 2622 Lake Ave Fort Wayne IN 46805-5410 Ph: (260) 425-3100 |
| NPI Number | 1811952070 |
|---|---|
| Provider Enumeration Date | 04/19/2006 |
| Last Update Date | 12/15/2015 |
| Medicare PECOS PAC ID | 2264413491 |
|---|---|
| Medicare Enrollment ID | O20040525001030 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811952070 | NPI | - | NPPES |
| 2629570 | Medicaid | OH | |
| 100268520 | Medicaid | IN |
| Provider Name | Samir Gamal Ishak |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1548257488 PECOS PAC ID: 4880655331 Enrollment ID: I20041019001023 |
| Provider Name | Judith L Zacher |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1124063102 PECOS PAC ID: 4284696477 Enrollment ID: I20041030000024 |
| Provider Name | Doyle E Lorenz |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1184689457 PECOS PAC ID: 5193789634 Enrollment ID: I20041115001235 |
| Provider Name | Theodore Sauer |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1881674703 PECOS PAC ID: 1456301258 Enrollment ID: I20050926000996 |
| Provider Name | Diana L Lackey |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1942341615 PECOS PAC ID: 6103911441 Enrollment ID: I20071002000688 |
| Provider Name | John B Brinkman |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1881668150 PECOS PAC ID: 6406752039 Enrollment ID: I20080502000060 |
| Provider Name | Christopher T Collie |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1427025550 PECOS PAC ID: 6406920982 Enrollment ID: I20080731000602 |
| Provider Name | Erin Eileen Rivera |
|---|---|
| Provider Type | Practitioner - Certified Clinical Nurse Specialist (cns) |
| Provider Identifiers | NPI Number: 1790893147 PECOS PAC ID: 8729140306 Enrollment ID: I20081216000073 |
| Provider Name | Loretta L Bazur-persing |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316192511 PECOS PAC ID: 9133283930 Enrollment ID: I20090122000519 |
| Provider Name | Minxin Fu |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1205952397 PECOS PAC ID: 2466502737 Enrollment ID: I20090608000318 |
| Provider Name | David A Sorg |
|---|---|
| Provider Type | Practitioner - Endocrinology |
| Provider Identifiers | NPI Number: 1154406957 PECOS PAC ID: 9638221674 Enrollment ID: I20090806000683 |
| Provider Name | John B Addo |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1922063189 PECOS PAC ID: 8123163391 Enrollment ID: I20100227000090 |
| Provider Name | Dorothea O Addo |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1063478360 PECOS PAC ID: 1759426927 Enrollment ID: I20100227000106 |
| Provider Name | Pamela Kinder Fountain |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194955757 PECOS PAC ID: 3173651619 Enrollment ID: I20100504000806 |
| Provider Name | Mark D Dabagia |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1891795852 PECOS PAC ID: 4385773027 Enrollment ID: I20100518000925 |
| Provider Name | Marcia K Grant |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1013076413 PECOS PAC ID: 8820127681 Enrollment ID: I20100603000812 |
| Provider Name | Donald Eugene Berman |
|---|---|
| Provider Type | Practitioner - Pulmonary Disease |
| Provider Identifiers | NPI Number: 1730102252 PECOS PAC ID: 1052312386 Enrollment ID: I20100804000705 |
| Provider Name | Sarah A Brady |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477864239 PECOS PAC ID: 3779617485 Enrollment ID: I20100817001011 |
| Provider Name | Desiderio Pina |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1043206998 PECOS PAC ID: 2961305867 Enrollment ID: I20100818000247 |
| Provider Name | Thomas P Ryan |
|---|---|
| Provider Type | Practitioner - Cardiovascular Disease (cardiology) |
| Provider Identifiers | NPI Number: 1275507055 PECOS PAC ID: 0648462564 Enrollment ID: I20101011001119 |
| Provider Name | Robert D Barnes |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1629008024 PECOS PAC ID: 3274729728 Enrollment ID: I20101123000186 |
| Provider Name | Ashraf H Hanna |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1720153919 PECOS PAC ID: 3274713656 Enrollment ID: I20110203000079 |
| Provider Name | Mahnaz A Qazi |
|---|---|
| Provider Type | Practitioner - Emergency Medicine |
| Provider Identifiers | NPI Number: 1275740169 PECOS PAC ID: 1850578378 Enrollment ID: I20110610000191 |
| Provider Name | Arman H Siddiqui |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1447484167 PECOS PAC ID: 5698953016 Enrollment ID: I20110706000417 |
| Provider Name | George Martin |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1841222452 PECOS PAC ID: 5092873042 Enrollment ID: I20120809000200 |
| Provider Name | Sarah E Slocum |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1851640155 PECOS PAC ID: 0648422071 Enrollment ID: I20121212000223 |
| Provider Name | Michelle M Diss |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1497198568 PECOS PAC ID: 9537307400 Enrollment ID: I20130605000052 |
| Provider Name | Chelsea R Handshoe |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811338254 PECOS PAC ID: 1254565716 Enrollment ID: I20131016001228 |
| Provider Name | Sarah J Turner |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1609162676 PECOS PAC ID: 7416107024 Enrollment ID: I20131112001984 |
| Provider Name | Christopher B King |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1962637652 PECOS PAC ID: 8325264617 Enrollment ID: I20140722002284 |
| Provider Name | Yokesh Balaraman |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1134431927 PECOS PAC ID: 1456597236 Enrollment ID: I20150108001505 |
| Provider Name | Rudolph N Bowens |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1487972527 PECOS PAC ID: 5395985899 Enrollment ID: I20150603001229 |
| Provider Name | Abdillahi M Abdinoor |
|---|---|
| Provider Type | Practitioner - Gastroenterology |
| Provider Identifiers | NPI Number: 1336377043 PECOS PAC ID: 2163731183 Enrollment ID: I20151014000989 |
| Provider Name | Judith E Ritholz |
|---|---|
| Provider Type | Practitioner - Pulmonary Disease |
| Provider Identifiers | NPI Number: 1043247042 PECOS PAC ID: 4284683426 Enrollment ID: I20160420000598 |
| Provider Name | Matthew A Byers |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1124314398 PECOS PAC ID: 5294025185 Enrollment ID: I20160606001204 |
| Provider Name | Basem Alsarraj |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1124381942 PECOS PAC ID: 3173820891 Enrollment ID: I20160621000961 |
| Provider Name | Ibad Ul-haq Farooqui |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1427499318 PECOS PAC ID: 8224260062 Enrollment ID: I20160726000218 |
| Provider Name | Kanika Jaggi |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1073954962 PECOS PAC ID: 7618109448 Enrollment ID: I20160726000383 |
| Provider Name | David Rydell |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1578509535 PECOS PAC ID: 2769426329 Enrollment ID: I20160922002732 |
| Provider Name | Hadi Farouk Shaaban |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1659529196 PECOS PAC ID: 4385879378 Enrollment ID: I20161212000299 |
| Provider Name | Kathleen Hollis Hammonds |
|---|---|
| Provider Type | Practitioner - Pulmonary Disease |
| Provider Identifiers | NPI Number: 1235336777 PECOS PAC ID: 1951538263 Enrollment ID: I20170601002506 |
| Provider Name | Viswanath Natesan |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1336117928 PECOS PAC ID: 7012951932 Enrollment ID: I20171012001069 |
| Provider Name | Nizar Fayez Olabi |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1023004504 PECOS PAC ID: 3274529409 Enrollment ID: I20180103000320 |
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