Basic Information
| Provider Information | |||||||||
| NPI: | 1376579565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN'S MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2631 CUNNINGHAM AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176278967 | ||||||||
| FaxNumber: | 4176278951 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 N HOSPITAL DR | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | GIRARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667432014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207244659 | ||||||||
| FaxNumber: | 6207246955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EBMEIER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4176278969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.