1083737704 NPI number — ST JOHNS CLINIC INC

Table of content: (NPI 1083737704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083737704 NPI number — ST JOHNS CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHNS CLINIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SJC-FAMILY MEDICINE/PEDIATRICS-HEALTHTRACKS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083737704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65801-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4331 S FREMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-7328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-5015
Provider Business Practice Location Address Fax Number:
417-820-5026
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSEN
Authorized Official First Name:
DONN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
417-829-4264

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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