Provider Demographics
NPI:1710923636
Name:ST. JOHN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:ST. JOHN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-627-8930
Mailing Address - Street 1:1701 W 26TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1513
Mailing Address - Country:US
Mailing Address - Phone:417-267-8967
Mailing Address - Fax:417-627-8920
Practice Address - Street 1:805 BARKER DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:KS
Practice Address - Zip Code:67356-9034
Practice Address - Country:US
Practice Address - Phone:620-795-2525
Practice Address - Fax:620-795-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178983Medicare ID - Type UnspecifiedRHC GROUP PROVIDER #