Provider Demographics
NPI:1376579565
Name:ST. JOHN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:ST. JOHN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EBMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-627-8969
Mailing Address - Street 1:2631 CUNNINGHAM AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1543
Mailing Address - Country:US
Mailing Address - Phone:417-627-8967
Mailing Address - Fax:417-627-8951
Practice Address - Street 1:307 N HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GIRARD
Practice Address - State:KS
Practice Address - Zip Code:66743-2014
Practice Address - Country:US
Practice Address - Phone:620-724-4659
Practice Address - Fax:620-724-6955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178974Medicare ID - Type UnspecifiedRHC GROUP PROVIDER #