Provider Demographics
NPI:1619083433
Name:ST. JOHN'S REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOHN'S REGIONAL MEDICAL CENTER
Other - Org Name:ST. JOHN'S REGIONAL MEDICAL CENTER HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-781-2727
Mailing Address - Street 1:4500 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4404
Mailing Address - Country:US
Mailing Address - Phone:417-623-8164
Mailing Address - Fax:417-623-1420
Practice Address - Street 1:4500 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4404
Practice Address - Country:US
Practice Address - Phone:417-623-8164
Practice Address - Fax:417-623-1420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO049-10HO251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820564508Medicaid
KS100000880MMedicaid
MO261512Medicare Oscar/Certification