Basic Information
| Provider Information | |||||||||
| NPI: | 1740316728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SJC-CASSVILLE | ||||||||
| 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: | 90 GRAVEL ST | ||||||||
| Address2: | |||||||||
| City: | CASSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656251601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178476045 | ||||||||
| FaxNumber: | 4178476049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4178294264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R4E21 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | 104182 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QR1300X | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 598833101 | 05 | MO | MEDICAID |