Basic Information
| Provider Information | |||||||||
| NPI: | 1497786859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN'S CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WILLIAM K. FLAKE, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 203 RICE ST | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726164388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704233338 | ||||||||
| FaxNumber: | 8704237330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4178206556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R2975 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 130968002 | 05 | AR | MEDICAID |