Provider Demographics
NPI:1770503187
Name:ST JOHNS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST JOHNS REGIONAL MEDICAL CENTER
Other - Org Name:ST JOHNS REGIONAL MEDICAL CENTER DEPT OF RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-659-6626
Mailing Address - Street 1:3436 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:800-525-7212
Mailing Address - Fax:
Practice Address - Street 1:2727 MCCLELLAND BLVD
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH INITIATIVES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS469128Medicaid
MO540564507Medicaid
KS100000880NMedicaid
174847OtherMO BLUE
OK100693700EMedicaid
137137OtherGHP
OK100693700EMedicaid
OK100693700EMedicaid
KS100000880NMedicaid