Provider Demographics
NPI:1053309211
Name:SISTERS OF ST. JOSEPH OF ST. MARK - MOUNT ST. JOSEPH
Entity type:Organization
Organization Name:SISTERS OF ST. JOSEPH OF ST. MARK - MOUNT ST. JOSEPH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SISTER MARY
Authorized Official - Middle Name:RAPHAEL
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LNHA
Authorized Official - Phone:216-531-7426
Mailing Address - Street 1:21800 CHARDON RD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-2125
Mailing Address - Country:US
Mailing Address - Phone:216-531-7426
Mailing Address - Fax:216-531-4033
Practice Address - Street 1:21800 CHARDON RD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-2125
Practice Address - Country:US
Practice Address - Phone:216-531-7426
Practice Address - Fax:216-531-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH206314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
365487OtherMEDICARE PROVIDER NUMBER