Basic Information
| Provider Information | |||||||||
| NPI: | 1902993728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176252910 | ||||||||
| Practice Location | |||||||||
| Address1: | 2931 MCCLELLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176252910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | PULSIPHER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT 7 CEO | ||||||||
| AuthorizedOfficialTelephone: | 4177812727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CATHOLIC HEALTH INITIATIVES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 11848 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100000880A | 01 | KS | MEDICAID | OTHER | 100693700A | 01 | OK | MEDICAID | OTHER | 010564508 | 05 | MO | MEDICAID |