Basic Information
| Provider Information | |||||||||
| NPI: | 1235173840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN'S PHYSICIANS & CLINICS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | ST. JOHN'S PHYSICIANS & CLINICS, INC. | ||||||||
| Address2: | 1312 E. LARK | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294264 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | ST. JOHN'S PHYSICIANS & CLINICS, INC. | ||||||||
| Address2: | 620 S. GLENSTONE | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4178206556 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.