Provider Demographics
NPI:1497786859
Name:ST. JOHN'S CLINIC, INC.
Entity Type:Organization
Organization Name:ST. JOHN'S CLINIC, INC.
Other - Org Name:WILLIAM K. FLAKE, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-6556
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:203 RICE ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4388
Practice Address - Country:US
Practice Address - Phone:870-423-3338
Practice Address - Fax:870-423-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR2975208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130968002Medicaid
AR130968002Medicaid