1366486052 NPI number — ST. JOHN'S PHYSICIANS & CLINICS, INC.

Table of content: (NPI 1366486052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366486052 NPI number — ST. JOHN'S PHYSICIANS & CLINICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHN'S PHYSICIANS & CLINICS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366486052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1965 S FREMONT AVE
Provider Second Line Business Mailing Address:
ST. JOHN'S PHYSICIANS & CLINICS, INC.
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4264
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 S GLENSTONE AVE
Provider Second Line Business Practice Location Address:
ST. JOHN'S PHYSICIANS & CLINICS, INC.
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65802-3206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-829-4620
Provider Business Practice Location Address Fax Number:
417-829-4316
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSEN
Authorized Official First Name:
DONN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
SENIOR VICE PRESIDENT/COO
Authorized Official Telephone Number:
417-820-6556

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 502606502 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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