Provider Demographics
NPI:1093802811
Name:ST JOHNS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST JOHNS REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:C
Authorized Official - Last Name:DANDRIDGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:417-625-2232
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-1240
Mailing Address - Country:US
Mailing Address - Phone:417-627-8930
Mailing Address - Fax:417-627-8920
Practice Address - Street 1:2727 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1695
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:417-625-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000260001001OtherBLUE CROSS OF OKLAHOMA
100000880COtherKANSAS MEDICAID
MD200900OtherBLACK LUNG
MO540564507Medicaid
100693700BOtherOKLAHOMA MEDICAID
MO101PD001OtherMO BLUE CROSS
KS007750OtherFAMILY HEALTH PARTNERS
MO440548809OtherRAILROAD MEDICARE
MO=========OtherTRICARE
50051Medicare ID - Type Unspecified