Provider Demographics
NPI:1639255243
Name:ST. JOHN DIALYSIS, LLC
Entity Type:Organization
Organization Name:ST. JOHN DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
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 1:1013 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4516
Practice Address - Country:US
Practice Address - Phone:918-227-3351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-27
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2265261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000370114001OtherBCBS
OK000370114001OtherBCBS