Provider Demographics
NPI:1417065764
Name:SAINT JOHN'S HEALTH SYSTEM
Entity Type:Organization
Organization Name:SAINT JOHN'S HEALTH SYSTEM
Other - Org Name:CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-646-8105
Mailing Address - Street 1:15 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4306
Mailing Address - Country:US
Mailing Address - Phone:765-646-8299
Mailing Address - Fax:765-646-8672
Practice Address - Street 1:15 W 19TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4306
Practice Address - Country:US
Practice Address - Phone:765-646-8299
Practice Address - Fax:765-646-8672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty