Provider Demographics
NPI:1760470652
Name:ST. JOHN CLINIC MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOHN CLINIC MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-576-0231
Mailing Address - Street 1:161 NW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-3929
Mailing Address - Country:US
Mailing Address - Phone:305-576-0231
Mailing Address - Fax:305-573-1458
Practice Address - Street 1:161 NW 29TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-3929
Practice Address - Country:US
Practice Address - Phone:305-576-0231
Practice Address - Fax:305-573-1458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X, 261QM1300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4624OtherTOTAL HEALTH CHOICE
FL060387200Medicaid
FL060387200Medicaid