Provider Demographics
NPI:1578656161
Name:ST JOHN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST JOHN MEDICAL CENTER INC
Other - Org Name:BERNSEN REHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SR. M. THERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTSCHALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-744-2180
Mailing Address - Street 1:1923 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-744-2345
Mailing Address - Fax:
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2265273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000370114001OtherBCBS OF OK
OK74104 0000OtherCHAMPUS
OK100699400AMedicaid
OK100699400AMedicaid