Provider Demographics
NPI:1639284920
Name:ST JOHNS MEDICAL CENTER PA
Entity Type:Organization
Organization Name:ST JOHNS MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-645-7559
Mailing Address - Street 1:2511 ST. JOHNS BLUFF RD. SO.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246
Mailing Address - Country:US
Mailing Address - Phone:904-645-7559
Mailing Address - Fax:904-241-0255
Practice Address - Street 1:2511 ST. JOHNS BLUFF RD. SO.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246
Practice Address - Country:US
Practice Address - Phone:904-645-7559
Practice Address - Fax:904-241-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382083100Medicaid
FLAJ829Medicare PIN
FL382083100Medicaid