Basic Information
| Provider Information | |||||||||
| NPI: | 1174812523 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOHN'S REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176596678 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | WOUND CARE | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176596678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | WOUND CARE NURSE | ||||||||
| AuthorizedOfficialTelephone: | 4177812727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN,WCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 123823 | MO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 123823 | 01 | MO | RN | OTHER |