Basic Information
| Provider Information | |||||||||
| NPI: | 1710187588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS CLINIC INC | ||||||||
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| OtherOrganizationName: | SJC WOMEN'S HEALTH HUNTSVILLE | ||||||||
| 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: | 705 PHILLIPS | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797381700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178294264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | E4990 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5F873 | 01 | AR | AR BLUE SHIELD | OTHER | 166387002 | 05 | AR | MEDICAID |