Provider Demographics
NPI:1669631792
Name:ST JOHN SAPULPA, INC
Entity Type:Organization
Organization Name:ST JOHN SAPULPA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
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:918-227-8601
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74067-1368
Mailing Address - Country:US
Mailing Address - Phone:918-224-4280
Mailing Address - Fax:918-224-6290
Practice Address - Street 1:1004 E BRYAN AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4513
Practice Address - Country:US
Practice Address - Phone:918-224-4280
Practice Address - Fax:918-224-6290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOHN SAPULPA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-04
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2310282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000370033001OtherBLUE CROSS BLUE SHIELD
OK100699550Medicaid
OK000370033001OtherBLUE CROSS BLUE SHIELD