Basic Information
| Provider Information | |||||||||
| NPI: | 1528564929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN PHYSICIANS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SJC OUTPATIENT DIABETES CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 S UTICA AVE # DT1000 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741046520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187442630 | ||||||||
| FaxNumber: | 9187442946 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717B S UTICA AVE STE 205 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187442444 | ||||||||
| FaxNumber: | 9187442483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 04/04/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISSEL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | BRYAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9187487617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOHN PHYSICIANS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 163WD0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 133V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.