Basic Information
| Provider Information | |||||||||
| NPI: | 1447218482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHEAST ST. JOHN'S HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 BEAM AVE | ||||||||
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| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327000 | ||||||||
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| Address1: | 1575 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 282N00000X | 330904 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 410852300 | 05 | MN | MEDICAID |