Provider Demographics
NPI:1790717270
Name:ST JOHN CARDIOVASCULAR MEDICINE INC
Entity Type:Organization
Organization Name:ST JOHN CARDIOVASCULAR MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEX
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-744-3674
Mailing Address - Street 1:1923 E 21ST ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1419
Mailing Address - Country:US
Mailing Address - Phone:918-744-6966
Mailing Address - Fax:918-744-9642
Practice Address - Street 1:1923 E 21ST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1419
Practice Address - Country:US
Practice Address - Phone:918-744-6966
Practice Address - Fax:918-744-9642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDE4213OtherRR MEDICARE