Basic Information
| Provider Information | |||||||||
| NPI: | 1700032653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHN'S REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | 21ST CENTURY ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648020760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176243040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | MENTGEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4176596700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.