Basic Information
| Provider Information | |||||||||
| NPI: | 1093802811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1240 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648021240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176278930 | ||||||||
| FaxNumber: | 4176278920 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176252910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | DANDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4176252232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000260001001 | 01 | OK | BLUE CROSS OF OKLAHOMA | OTHER | 100000880C | 01 | KANSAS MEDICAID | OTHER | 200900 | 01 | MD | BLACK LUNG | OTHER | 540564507 | 05 | MO | MEDICAID | 100693700B | 01 | OKLAHOMA MEDICAID | OTHER | 101PD001 | 01 | MO | MO BLUE CROSS | OTHER | 007750 | 01 | KS | FAMILY HEALTH PARTNERS | OTHER | 440548809 | 01 | MO | RAILROAD MEDICARE | OTHER |