Basic Information
| Provider Information | |||||||||
| NPI: | 1447439633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 613 ORCHARD DR | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726165013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704234240 | ||||||||
| FaxNumber: | 8704234241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4178294264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | M00127 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.