Provider Demographics
NPI:1497988596
Name:ST. JOHN BROKEN ARROW, INC
Entity Type:Organization
Organization Name:ST. JOHN BROKEN ARROW, INC
Other - Org Name:ST. JOHN BROKEN ARROW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-994-8100
Mailing Address - Street 1:1000 W BOISE CIR
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4900
Mailing Address - Country:US
Mailing Address - Phone:918-994-8100
Mailing Address - Fax:918-994-8199
Practice Address - Street 1:1000 W BOISE CIR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4900
Practice Address - Country:US
Practice Address - Phone:918-994-8100
Practice Address - Fax:918-994-8199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-24
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2380282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
370235OtherMEDICARE CCN